Dysfunctional Affect Regulation

In Borderline Personal ity Disorder & Somatoform Disorder

Annemiek van Dijke

ISBN: 978-94-6169-071-5 Print and Layout by Optima Grafische Communicatie, Rotterdam

Dysfunctional Affect Regulation
in borderline personality disorder and somatoform disorder

Disfunctionele Affect Regulatie
in borderline persoonlijkheidsstoornis en somatoforme stoornis (met een samenvatting in het Nederlands)

Proefschrift
ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op vrijdag 10 juni 2011 des middags te 2.30 uur

door

Annemiek van Dijke geboren op 21 juli 1969 te Hulst

van der Hart Prof dr. M.J. van der Heijden Dit proefschrift werd (mede) mogelijk gemaakt met financiële steun van Delta Psychiatrisch Centrum.G.PROMOTORES: Prof dr. van Son Prof dr. P. .M. O.M.

TABLE OF CONTENTS Chapter one Chapter two Introduction and outline Affect Dysregulation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Under.and OverRegulation Affect Dysregulation and Dissociation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Inhibitory and Excitatory Experiencing States Childhood Traumatization by Primary Caretaker and Affect Dysregulation in Patients with Borderline Personality Disorder and/or Somatoform Disorder Complex Posttraumatic Stress Disorder in Patients with Borderline Personality Disorder and Somatoform Disorders The Clinical Assessment and Treatment of Trauma-related Selfand Affect Dysregulation Discussion 7 19 Chapter three 33 Chapter four 49 Chapter five 65 Chapter six 77 Chapter seven Summary 95 107 113 119 139 147 Samenvatting in het Nederlands References Acknowledgements Curriculum Vitae .

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Chapter One Introduction and outline .

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The . The attempt to self regulate is dysfunctional here in the way that the psychological burden (intolerable emotional arousal) could not be contained and was expressed in physical symptoms. called names.” A 27-year old man (semi-professional ice-skater) was admitted to the clinic when the rehabilitation of his broken leg was not progressing well. During his visits to the rehabilitation center he had presented with emotional explosiveness and self-harming behavior that he seemed unable to recognize as a problem. The first vignette highlights the incapacity to emotionally express oneself verbally when confronted with intolerable affect. Three days later she was able to talk about what happened earlier that particular day. He stated that his leg continued to feel weak and unstable. while the core of the problem was not addressed. Chapter One 9 Introduction and outline A 30-year old woman flew into a rage. These three vignettes can be regarded examples of dysfunctional self-regulation and affectregulation in response to social emotion-eliciting situations.00 hrs. It seemed that she had telephoned the receptionist of the outpatient facility on Friday 17. she developed the pseudo-epileptic seizure. such that emotions instead are somatically expressed and become over-regulated. and could not return to baseline-arousal until several hours later after extensive reassurance by the group members and clinicians that she was “being a good girl. and he had just heard that his potentially professional career as an ice-skater was over. Unfortunately. analyzing and verbalizing emotions hinders dealing with challenges in every-day life. Difficulties differentiating. She continued to be highly aroused. and became hyperaroused during group therapy when she was asked to wait with her contribution to the discussion and first listen to reflections of her group members on her behavior. because she wanted to talk to her psychotherapist.INTRODUCTION A 42-year old woman developed a full blown pseudo-epileptic seizure. Subsequent to hearing this. The second vignette highlights under-regulation of affect and the difficulties one can have regulating levels of arousal to baseline and keeping emotions within a window of tolerance in interpersonal contexts that have personal or posttraumatic significance. the psychotherapist had already gone on week-end leave.

Dysfunctional regulation is often described in patients with complex psychopathology and mental disorders.. 1998). empirically. Naring. However. et al. arousal and distress could no longer be channeled or expressed in a physical way. and the intensive sports exercises that he engaged in as a result of his semi-professional athletic career may have helped him regulate himself. and axis II. & Moene. it has been established that affect dysregulation is involved in the etiology of psychopathology (e. Roelofs. However.. destructive relationship management. Two mental disorders that have been theoretically. Silbersweig. 2004). his career. Linehan. when confronted with forced immobility.g. et al. and problems with mentalization that make it difficult for .IV-TR axis I. Some even considered BPD (e. The apparent regression reflected by the patient’s need (or the group members’ perception of her as needing) to be soothed like a young child suggests that this under-regulation of affect may originate in much earlier life experiences in which the patient may not have been provided with (or able to accept and utilize) responsive caregiving.. and axis III disorders. Borderline Personality Disorder Patients with BPD have long been recognized as creating extraordinary challenges for the clinicians who treat them (e. Hoogduin. Nyklíc et al. 2004).g. impulsive behavior. Bradley. and his future). and historically associated with affect dysregulation are borderline personality disorder (BPD. leading him to have unanticipated difficulties recognizing.g. Bateman & Fonagy. 10 Affect Dysregulation and the Development of Psychopathology Despite a vast amount of research on the benefits of successfully regulating affect for our mental and somatic well-being (e. 2002). describing and expressing his emotions except in the form of frustration and impulsivity.. 1993.agitated response elicited by what appeared to be relatively mild limit-setting from the group leader and feedback from group members is indicative of the patient’s difficulty in both maintaining emotional arousal within a tolerable window and recovering from distress. and it is also considered to be a maintenance factor or predictor of attrition and poor therapy outcome (Ford & Kidd. dysfunctional affect regulaˇek tion for psychiatric patients remains unclear.. 2004) and somatoform disorders (SoD. 2006) primarily to be disorders of affect regulation.. 2000). APA. As a result.g. The third vignette highlights the combination of a highly aroused affective experiencing while reporting diminished capacity for self-reflection and emotional self-awareness. 2006) and SoD (Waller & Scheidt. Keijsers. this man may be experiencing a combination of difficulties with over-regulation (his characteristic mode of coping) and under-regulation (his reaction to an unprecedented physical crisis that may have shaken his confidence in himself. such as a combination of DSM. It may be the case that symptoms of dysfunctional affect regulation were already present before this man broke his leg. 2007. The major reasons for the treatment difficulties encountered are patterns of intense affectivity. Linehan.

ar et al.. and integrative difficulties (e.. failure in successfully down regulating negative affect (e. The major . or a surplus of physical symptoms upon medically explained illness (APA. failure of keeping affects within a window of tolerance (Siegel. Wyshak. The category of somatoform disorders has been long under debate (e.. 2003.g. developmental anomalies in the construction of the (social) brain (e... difficulties executive functioning (e. 2004). 1999). Lenzenweger. Kroenke. Bell. 2005). 2006. 2006). i. dysfunctional affect regulation in BPD-literature has been primarily conceptualized as being hyper-aroused and being overwhelmed with negative affect: under-regulated affective experiencing.. pain disorder. & Ertem-Vehid. & Kernberg. Two main shortcomings are that somatoform disorders do not form a coherent category and that subcategories are unreliable (Mayou et al. Cozolino. However. 1986). Öztürk. 2009). 1999. and body dysmorphic disorder have been associated with anxiety. Clarkin.e. Symptoms are not consciously produced in contrast to malingering. Convincing patients with somatoform disorder that they need psychological treatment is not easy (Mayou et al. distortions in information processing (e. 2006). & Pain. Mayou et al.g. Obviously. in which one fakes a symptom in order to avoid a test or military service.g.g. Fertuck.g. one of the great difficulties in diagnosing somatoform disorders is the possibility that one has a real physical disorder that is simply difficult to detect or diagnose. and dissociation (e. 2004). Kirmayer. Ford. 2008). 1993)... 2006). Minton... Fosha..g. Dysfunctional regulation in BPD has been associated with affect intolerance (Krystal. despite all the physicians’ conclusions and test results that have established no physical illness.. affect phobia (McCullough et al.. ar. nor are symptoms controlled or managed in contrast to factitious disorder or Munchhausen syndrome.g. Linehan. and undifferentiated somatoform disorders have been primarily associated with affect dysregulation (Waller & Scheid.g. 2006). & Solomon. & Klerman. 2004. frantic anxiety associated with the anticipation of the separation of loved-ones (e. conversion disorder. Salkovskis & Warwick. difficulties facial affect labeling (Wagner & Linehan.. 2008). Mayou.the patient to reflect upon these patterns (Allen & Fonagy. Roelofs et al. Simon. Instead. 2003).g.. Chapter One 11 Introduction and outline Somatoform Disorders Somatoform disorders are a group of disorders in which one experiences significant physical symptoms for which there is no apparent organic cause. diagnosing and treating this group of patients is considered a challenging enterprise for clinicians (Mayou et al. failure of overcoming self-destructive behavior (e. Kugu. a complex of early and later life-trauma (e. fear of physical illness and fear of deformation of body parts and social rejection (Barsky. Hoermann. Siegel. 2006). 2008).g.. Clarkin. one truly experiences these symptoms. 2008. & Sharpe.. Yeomans. failure of mentalizing (e. Allen & Fonagy. Somatization disorder. & Stanley. 2005). They tend to hold tightly to the belief that they are physically ill. While hypochondriasis. Ogden. Akyuz. 2002).g. in which one fakes or establishes physical harm onto one self or to one’s child (-by proxy) in order to get medical attention. Therefore. 2003). 1988). 2006). 2008).

1988) highlighted the anxiety-buffering and physical protection functions of close relationships and conceptualized proximity-seeking as an affectively regulated alternative to the instinctive and typically dysregulated fight-flight responses. 2006).g. and having difficulties addressing emotions: over-regulated affective experiencing. relational. 1994). 2006) and insecure attachment relationships (Scheidt & Waller. 2004). Parker. Smyth. Carson. Bowlby (e. result in hyper-activation of the attachment system (Mikulincer. reflective. Denollet & Nyklicek. Shaver. la belle indifférence (Stone.. whereas experiences associated with sense of dependence and fear of being alone. & Sharpe. somatic.. Dysfunctional regulation may presents in patients in three qualitatively different forms: Inhibitory-. Taylor. la pensée opératoire (operative thinking. In line with this. lack of psychological mindedness (e. Warlow. 1970). Attachment theory has become a prominent conceptual framework for understanding the process of development of affect regulation and dysregulation (Allen & Fonagy. & Pereg 2003). are being physically focused. diminished emotional awareness (e. & Evans. Experiences associated with proximity to the attachment figure as non-rewarding or punitive. and problems with mentalising that make it difficult to reflect upon these patterns (Allen & Fonagy. integrative difficulties (Nijenhuis. and psycho-physiological functioning. argumentative relationship management.reasons for the treatment difficulties encountered here. In all these studies. However. Activation of dysfunctional regulation seems to follow trauma-by-primary-caretaker associated negatively biased cognitive-emotional information processing (Van Harmelen. 1987). and combined Inhibitory & Excitatory (IE)-regulation.g.g. it’s associated phenomena and retrospectively reported potentially traumatizing events in patients diagnosed with BPD and SoD. executive. clinical presentation with numbness and lack of affectivity. 2006). Shulman... 2004). Excitatory-. cognitive. Lane & Schwartz. Dysregulation in SoD has been associated with affect intolerance (Krystal. Affect dysregulation typically seems to involve an interpersonal context. behavioral. 2004). Van Dijke (2008) described dysfunctional regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective. dysregulated affect in SoD has been primarily conceptualized as being numb or inhibited. poor fantasy life (Nemiah & Sifneos. result in a de-activation of the attachment system. et al. Kuch. Symptoms include disturbances in self-regulation across several domains of functioning including affective. 2004). 2010). 12 Aim and Outline The aim of this thesis is to provide a systematic exploration of the nature and distribution of dysfunctional affect regulation. when potentially neutral situations are . 1988). alexithymia (Cox. others react hyper-emotionally and tend to cling to a significant other to alleviate stress and regulate to base-line. He also emphasized the importance of interpersonal (traumatic) experiences as sources of individual differences in affect (dys)regulation across the lifespan. Whereas some patients react to adversities with inhibited experiencing and social withdrawal.

negative psychoform and somatoform dissociation. and the distribution of complex PTSD associated symptoms in our study groups. and optimism (Mikulincer & Shaver. Consequently. as well as in a psychiatric comparison (PC) group to assess how dysfunctional affect regulation is differentially distributed among all study groups. Figure 1 summarizes the hypothesized relationships for dysfunctional regulation that were discussed above. fear of abandonment in adult relationships. positive psychoform and somatoform dissociation. It should be noted that dysfunctionally regulated persons. this results in interpersonal misunderstanding and disappointments. overregulation of affect. resilience. results were included in a psychological assessment-report for each patient resulting in indication of treatment choice. pseudo mentalization. overly executive functioning. Inhibitory regulation when activated based upon biased (negativeavoidant) cognitive-emotional information processing encompasses. risk to never meet the sense of personal efficacy. which in turn condition and uphold the insecure attachment representation/ working models turning into inhibitory regulation vicious circle. both forms of dysfunctional affect regulation were also assessed in a group consisting of patients diagnosed with comorbid BPD+SoD. Chapter One 13 Introduction and outline Naturalistic Study The study was executed in two mental institutions in the Netherlands. and dominance of the sympathetic system. all clinicians and participating junior-researchers were instructed in the rationale of the project and were trained and supervised in order to be able to interview and/ or collect data. under regulation of affect. narrowed executive functioning. Excitatory regulation when activated based upon biased (negative-anxious) cognitive-emotional information processing encompasses e. The focus of the thesis will be on dysfunctional regulation domains affect. the protocol was implemented in daily routine.. which in turn conditions and upholds the insecure attachment representation/ working models turning into an excitatory regulation vicious circle. among others.g. 2004). In order to enhance feasibility. dysfunctional regulation is activated false positively. fear of closeness in adult relationships. inhibited mentalization. . when confronted with internal or external adverse events. and dominance of the dorsal vagal system. this results in interpersonal misunderstanding and disappointments. Combined Inhibitory & Excitatory (IE)-regulation encompasses both inhibitory and excitatory domains and symptoms that can present alternating or in combinations in patients. the relations with potentially traumatizing events-by-the-primarycaretaker while differentiating developmental epochs. immobilizing action tendencies. that is. mobilizing action tendencies. Not all hypothesized relationships presented in the figure could be studied within the scope of this thesis. As BPD and SoD occur also comorbidly. Consequently. cognition and soma. Data collected serve also a direct clinical aim.processed and evaluated as threatening or potentially harmful.

under-regulation of affect and intense and overwhelming emotion S . other and self-other relatedness” activating -when exposed to adverse or ambiguous/ neutral (interpersonal) situationsinsecure cognitive-emotional-information processing and dysfunctional regulation encompassing: 14 mainly Inhibitory regulation A – over-regulation of affect and numbness and inhibition of emotion S .Negative Psychoform Dissociative symptoms I .overly executive (haording) B – mobilizing action tendencies PF – sympathic system dominance interpersonal difficulties & psychological difficulties confirming Insecure attachment representations Figure 1. Mikulincer & Shaver. The differential conceptualization of dysfunctional affect regulation raises the question if two qualitatively different forms of dysfunctional affect regulation do exist and whether these two forms are indeed differentially distributed among patients diagnosed with BPD or SoD. the quality of dysfunctional affect regulation seems differentially conceptualized. fearful exec disorientation disoriented both mainly Excitatory regulation A. S=soma. I=interaction. no study systematically assessed both forms of dysfunctional affect regulation in BPD and SoD in unison. .inhibited Mentalization/ ED .Negative Somatoform Dissociative symptoms C . Also. R=reflective function. B=behavior. SoD has been primarily associated with numbing and difficulties differentiating. and verbalizing emotions. Reviewing the literature. If BPD is indeed a disorder of affect regulation and if indeed dysfunctional affect regulation involves being overwhelmed with negative affective experiencing and having difficulties down-regulating negative affect. Whereas BPD has been primarily associated with hyper-arousal and being overwhelmed with emotions.Positive Somatoform Dissociative symptoms C . PF= psycho-physiological. Dysfunctional Regulation Operating in Vicious Cycles NB: A=affect.g.narrowing executive function B .Fear of closeness/ dismissive R .Emphasis on Self reliance Experience of proximity as non-rewarding/punishment Tendency to perceive the non-viability of proximity seeking De-activation of attachment system internalized history of trauma-by-prim caretaker Emphasis on Helplessness Sense of dependence & fear of being alone High costs for perceiving the viability of proximity seeking hyper-activation of attachment system e.dorsal vagal dominance mainly Combined . . lines in light print were not included in the thesis Are There Qualitatively Different Forms of Dysfunctional Affect Regulation? Although BPD and SoD are each considered to be disorders of affect regulation..immobilizing action tendencies PF . 2003 Insecure attachment representations containing information on “self.Positive Psychoform Dissociative symptoms I – Fear of abandonment/ preoccupied R – pseudo Mentalization/ ED . then all patients diagnosed with BPD should report underregulation of affect and significantly more so than other study groups.. C=cognition. if SoD is indeed a disorder of affect regulation and if dysfunctional affect regulation involves being numb or . analyzing.. ED=exec dysfunction.

for example. Van der Hart. Negative somatoform dissociative symptoms. skills. analgesia. Janet (1889) introduced his model of the mind consisting of two different ways the mind functions: (a) activities that preserve and reproduce the past. and amplified affective experiencing. among others. 2009). than other study groups. if there are indeed two qualitatively different forms of dysfunctional affect regulation present in BPD and SoD. e. and significantly more so. Negative dissociative symptoms refer to apparent losses of functions. and aphonia. The results are described and discussed on their clinical and empirical merits in chapter two. 1901. and (b) activities which are directed towards synthesis and creation (i. and diminished sense of self. include loss of memory (amnesia) and loss of affective experiencing (numbness). Van Dijke. 2006. 1907). 2006). motor control. Already in Janet’s original research (and recently further conceptualized). or disoriented (Courtois & Ford. 1 In the literature. Nijenhuis & Van der Hart. 2004. and having difficulties addressing emotions. Nijenhuis. loss of previously existing skills. such as dissociative parts of the personality (Van der Hart et al. Janet. the existence of dissociative subsystems manifests in positive and negative dissociative symptoms (e. and somatosensory awareness. paralysis. However. loss of critical function (a cognitive action) resulting in suggestibility and difficulty thinking things through. Van der Hart et al.. Van der Hart and colleagues (2006. Negative psychoform dissociative symptoms. cognitive and somatosensory components such as dissociative flashbacks and full re-experiencing of traumatizing events. 15 Introduction and outline .. of memory. Positive psychoform dissociative symptoms include traumatic memories and nightmares that have affective.g. involve losses of sensory. In line with Janet. 1901. Furthermore. Chapter One Are Positive and Negative Psychoform and Somatoform Dissociative Symptoms Related to Over.e. dissociative flashback episodes. Van Son. 1907. APA.. a psychiatric comparison group (PC) would not or would significantly less often report these forms of dysfunctional affect regulation. these subsystems have received various names. thoughts. then it might be expected that the comborbid BPD+SoD study group would report both forms of dysfunctional affect regulation.. 2004. in press) consider dissociation a core feature of trauma: a division of personality into dissociative (biopsychosocial) subsystems that evolve when the individual lacks the capacity to integrate adverse experiences in part or in full1. loss of needs and will (abulia). as well as intruding voices.g. & Steele. among others.. disorganized. then all patients diagnosed with SoD should report over-regulation of affect.and Under-regulation of Affect? Trauma-related overwhelming affect and it’s dysfunctional regulation compromises the integrative capacities associated with cognitive-emotional information processing so that information becomes disassociated. These positive and negative dissociative symptoms can be further distinguished as psychoform and somatoform dissociative symptoms (Janet. perceptual or motor functions. 2000).inhibited. integration).

most have not and report only of negative phenomena (e. dissociative flashback episodes. when compared to all other groups of patients. & Steele. The results of the exploration of the presence and distribution of inhibitory and excitatory experiencing are described and discussed on their clinical and empirical merits in chapter three. 2006). 16 What is the Relation between Dysfunctional Affect Regulation in Adulthood and Self-reported Chilhood Trauma-by-primary-caretaker. 2010.. Nijenhuis. Nijenhuis. For the comorbid BPD+SoD group. patients should be able to report distinct forms of experiencing: inhibitory and excitatory experiencing. Adverse childhood interpersonal experiences when compared to interpersonal adversities later in life or natural disasters result in more complex trauma-related symptoms (e. a review of the literature revealed that no empirical study exists that specifically addressed the relations between under. 2004. sensory distortions. 2001. and the development of psychopathology (Allen.. 1996). 7-12 y. The results of the exploration of the relation and distribution of potentially . Following Janet. 1999. and dissociation and dysfunctional affect regulation are related but distinct phenomena. there seem apparent similarities between the two qualitatively different forms of dysfunctional affect regulation and positive and negative dissociative symptoms. 2000. Lyons-Ruth et al. Roth. while Distinguishing Developmental Epochs Vulnerable for the Development of Affect Regulation? Several authors have addressed the negative impact of misattuned interaction and adverse interpersonal experiences on the post-natal development of the social-affective brain areas. Schore. reports of combinations of both forms of dysfunctional affect regulation with both positive and negative dissociation would be more expected. 2006. 1999). 2004. Courtois & Ford.Positive somatoform dissociative symptoms include intrusions of sensorimotor aspects of traumatic re-experiences. Harvey & Bryant.g. However. 1997. Inhibitory reports (reports of negative dissociation and over-regulation of affect) would be more expected in patients diagnosed with SoD. APA.. the social-emotional personality.. Mandel. 1999). Van der Hart et al. 2005. Pelcovitz.and overregulation of affect and the nature of the trauma-by-primary-caregiver (emotional. Excitatory reports (reports of positive dissociation and under-regulation of affect) would be more expected in patients diagnosed with BPD. If positive dissociative symptoms can be distinguished from negative dissociative phenomena by means of self report. and pseudo-epileptic seizures. & Resick. Siegel.g. 2009. Van der Hart. Van der Kolk et al. and sexual trauma) while distinguishing developmental epochs (0-6 y.. 1997.g. 1994... Roth. physical. Marshall et al. uncontrolled behaviors such as tics. Van der Kolk. Van der Kolk. Newman. including pain. & Mandel. However.. Reports of potentially traumatizing events in the developmental epoch 0 to 6 years would be associated with both and more dysfunctional affect regulation compared to reports in the developmental epochs 7-12 years of 13-18 years. Lanius et al. A few contemporary authors have noted the existence of positive dissociative symptoms (e. and 13-18 years) vulnerable for the development of affect regulation. Pelcovitz.

. 1996... 2009. 1992. Complex PTSD (CPTSD. 2006). Herman. & Spinazzola.. Pelcovitz.traumatizing events by the primary caretaker for developmental epochs and two forms of dysfunctional affect regulation are described and discussed in chapter four. somatoform disorders.. and complex PTSD symptom severity and syndromal prevalence. and shattered or altered basic beliefs.. WHO). 1996) or Disorders of Extreme Stress Not Otherwise Specified (DESNOS. Exposure to sustained.. 2009).. but also other symptoms reflecting disturbances predominantly in affective and interpersonal self-regulatory capacities (Cloitre et al. 1901. 1889. Chapter five discusses the results of this study of the differential distribution of complex PTSD and the comparison of complex PTSD symptoms for all study group in unison. symptoms of both BPD and SoD have been associated with interpersonal trauma and hysteria (Briquet. and dissociative disorders (cf.g. Van der Kolk et al. 2001). What is the Presence of Complex PTSD/ DESNOS in BPD and SoD? Historically. Van der Hart et al. with early childhood trauma exposure. 2005) was introduced. 1997. 1996). Roth. Some studies have reported an elevated risk of Complex PTSD symptoms in BPD (Ford. In most recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM. Chapter One 17 Introduction and outline . Sunday. 1997. Van der Kolk et al. has been proposed to result in a complex symptom presentation that includes not only dissociative and posttraumatic stress symptoms. 1859). repeated or multiple potentially traumatizing events.. Also. no study has systematically examined the association of BPD and SoD. separately and comorbidly. symptoms similar to those of hysteria are described not for one mental disorder but for several mental disorders. Zlotnick et al. In an attempt to capture this complex symptom presentation. that includes not only posttraumatic stress symptoms and dissociative symptoms. 1907). However. 2005). Pelcovitz et al. Van der Kolk. such as personality disorders. APA) and International Classification of Diseases (ICD. posttraumatic stress disorder. somatization. Roth et al. the association between trauma history and the development of a specific psychiatric disorder is complex: there is no one-to-one relation between certain forms of trauma and specific mental disorders (e. Janet (1859-1947) described perhaps most precisely the psychological disturbances and multiple medically unexplained and often chronic physical complaints presented by patients (Janet. but also disturbances in affective and interpersonal self-regulatory capacities. 1999. 1999) or report difficulties differentiating CPTSD from BPD (McLean & Gallop. 2003) and SoD (Spitzer et al. Van der Kolk.. Paivio & Laurent. This complex symptom presentation does not seem to be encompassed by any single DSM-IV-TR or ICD-10 disorder (Ford. particularly when a primary caretaker is involved. PTSD. It was hypothesized in this study that Complex PTSD is more frequently displayed in the comorbid BPD+SoD groups compared to all other study groups.

Integration of Theoretical Insights. and Research Findings in Clinical Practice: Work in Progress. Finally. evidence-based information. in close collaboration with two multi-disciplinary teams from Delta Psychiatric Hospital. summaries in Dutch and English are provided. Also. a protocol for clinical assessment and treatment of developmental trauma-related dysfunctional affective and interpersonal self-regulation was developed. their consequences for assessment and treatment are highlighted. This protocol originally was developed at the Department of Clinical and Health Psychology. 18 . and Altrecht Mental Health. and was later. the results of the studies presented in this thesis are summarized. Poortugaal. it is work in progress. Based on the existence of qualitatively different forms of trauma-related dysfunctional regulation. Utrecht University. Best Practices. the Netherlands implemented in daily clinical routine. Zeist. Moreover. The protocol is not considered to be a gold standard but rather an integration of theoretical perspectives. and some indications for future research are provided in chapter seven. Chapter six outlines the multi-disciplinary assessment and treatment as implemented in two clinical settings. and bestpractices that proved feasible and effective for these two multi-disciplinary teams.

. Van der Hart.. .J. A.M. J. Van Son.D. M.and OverRegulation Van Dijke. P. Ford. 296-311. M. O..Chapter two Affect Dysregulation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Under. Van der Heijden.M. 24.G. Journal of Personality Disorders.. Affect dysregulation in borderline personality disorder and somatoform disorder: Differentiating underand over-Regulation. & Bühring.. (2010).

and SoD was associated with overregulation of affect. Revised) and the BVAQ (Bermond Vorst Alexithymia Questionnaire). Conclusion Three qualitatively different forms of affect dysregulation were identified: under-regulation -. remarkably little research has focused on the prevalence and nature of affect dysregulation in these disorders. one in five patients with BPD also reported substantial overregulation. Methods 20 BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using two clinical interviews: the CIDI (Composite International Diagnostic Interview section C for somatoform disorders) and the BPDSI (Borderline Personality Disorder Severity Index). Affect dysregulation was measured using two self-reports: the SIDES-rev-NL (Structured Interview for Disorders of Extreme Stress Not Otherwise Specified. and the comorbid BPD & SoD group reported more frequently both over. and one in six patients with SoD reported clinically significant under-regulation.and over-regulation of affect .and underregulation than patients diagnosed with BPD or SoD alone or those with other psychiatric disorders.ABSTRACT Introduction Although affect dysregulation is considered a core component of borderline personality disorder (BPD) and somatoform disorders (SoD). Results BPD was associated with under-regulation of affect. However. over-regulation of affect and combined under.

2005.. Donegan.’ by distinguishing the two forms it is proposed that there may be two different mechanisms that can occur separately or potentially together. Bradley. Van Dijke (2008). Conklin. & Westen. 2004.e. Bolk. & Lynch. expressed in intense and unmodified forms. Brand. 2004. affect dysregulation has been referred to as involving: (1) emotional numbing and inhibition of emotion awareness. The findings of both studies are consistent with the hypothesis that BPD involves under-regulation of emotions. et al. neither study investigated the possibility of over-regulation of affect in BPD. 2006). Kooiman. in line with Fonagy. proposed that affect dysregulation may take two forms: “under-regulation” as observed in states of unmodulated emotional distress. 2003. Zittel Conklin. 2000.and Over-Regulation of Affect . which appear to be distinct constructs. & Rooijmans. McMain. Rolls. Banawan. 2006. affect dysregulation has been defined in two distinct ways. Using the Affect Regulation and Experience Q-sort-Questionnaire Version to assess affect dysregulation. 2006. however. and colleagues found that BPD patients are characterized by both negative affect and affect dysregulation.. 2002). Using the Affect Intensity Measure and Affect Control Scale to assess dimensions of affect regulation. Trijsburg. Bradley. 2001.. & Westen. & Dimeff. & Westen. Yen and colleagues concluded that persons with BPD traits experience emotions more intensely and have greater difficulty in controlling their affective responses than do other individuals. & Target (2002). (2) impairments in insight into emotions. 2007. 2004. and “over-regulation” as observed with alexithymia. and overwhelm reasoning and behavioral self-regulation (Koeningberg et al. and (4) difficulty analyzing emotions. 2005. Silbersweig et al. Ebner-Priemer.. Zittel. also known as alexithymia (Waller & Scheidt. and Westen. In the SoD literature. 2005. failure to modulate intense emotion states) Chapter two 21 Differentiating Dysfunctional Under. and Paivio and Laurent (2001). Waller & Scheidt. Berlin. Yen. 2006).. Under-regulation refers to impairment in modulation of affect (i. Some authors even consider BPD (Linehan. 2006. Although under-regulation of affect (i.INTRODUCTION Affect or emotion dysregulation is considered a core component in borderline personality disorder (BPD.. 2002. (3) difficulty verbalizing emotions. However. Korman. Burba et al. Two studies have provided quantitative descriptions of affect dysregulation in BPD (Zittel Conklin.. et al. Although the process of refining the concept of affect dysregulation is considered ‘work-in-progress.e. maintaining mid-range rather than extremely high or low levels of affective intensity) and in recovery from extreme states of affective intensity. 2006). & Costello. In BPD studies addressing affect dysregulation the focus was mainly on a deficiency in the capacity to modulate affect such that persons become over-aroused and emotions become uncontrolled. Harned. Gergely. 2006) to be primarily disorders of affect dysregulation. 2005) and somatoform disorder (SoD. 1993) and SoD (Waller & Scheidt. Zlotnick. In an attempt to clarify the concept of affect dysregulation. & Iversen. Zittel Conklin. Over-regulation refers to suppression or repression of affective awareness or expression. Zittel Conklin. Jurist.

For the psychiatric comparison group it was hypothesized that affect dysregulation should be of lesser severity in both under.. SoD. 2001. Waller & Scheidt. 1994. no empirical studies that systematically assess the presence of both forms of affect dysregulation in BPD or SoD appear in the literature. Some found evidence of a relationship between affect dysregulation (in the form of alexithymia on the TAS-20) and SoD (Burba et al. & Taylor. 2006. Centre for Personality Disorders.has been emphasized in clinical (Linehan. Parker. Brand. 2000. Perry & Herman. Although both BPD and SoD have been considered to be disorders of affect regulation. & Van Dijke. Cohen. that is: being over-aroused accompanied by inhibited emotion related cognitions and inhibited emotion related cognitive functions (Bermond. 2007) studies of BPD. 2008).. and all participants with SoD should report clinical levels of over-regulation of affect. 1993). 22 METHODS Participants and procedure Participants were 472 consecutive admissions to two adult inpatient psychiatric treatment centers. Delta Psychiatric Center. 2003). Bagby. & Taber 2003. evidence consistent with the possibility of problems with over-regulation also has been reported in studies of BPD (e. & Brooker. in this study both under-regulation and over-regulation of affect were assessed in patients who were diagnosed either with BPD. to our knowledge. Moormann. 2003. Johnson et al. or other psychiatric disorders (psychiatric comparison group. it was hypothesized that all participants diagnosed with BPD should report clinical levels of under-regulation.g. 2002). Hurley. & Bach.and over-regulation than for the patients with BPD or SoD or both. Auld. Duddu. PC). Altrecht Utrecht (N = 117) and De Waard. comorbid BPD+SoD. The results from studies on affect dysregulation in SoD patients are inconclusive. 2004.. Albach. 1994) than did non-clinical controls and their family members (Guttman & Laporte. Rotterdam (N = 355) who . 1993) and scientific (Johnson. For patients diagnosed with comorbid BPD and SoD it was hypothesized that they will report clinical levels of both under-regulation and over-regulation. No other studies that examined alexithymia and BPD could be located. If BPD and SoD are disorders of affect dysregulation. & Chaturvedi. Eikenboom Center for Psychosomatic Medicine. Kooiman. Aigner.. Therefore. Bolk. 2006). Isaac. & Rooijmans. emotional numbing and associated substance use problems. Trijsburg. Silbersweig et al. A study of adult female psychiatric patients with BPD found that they and their family members had higher levels of alexithymia on the Toronto Alexithymia Scale-20 (TAS-20. Benkelfat. Herpertz. while others studies did not find alexithymia and SoD or somatization to be related (Bankier. dissociation.

borderline personality disorder and somatoform disorder. BPD+SoD. borderline personality disorder. according to the Declaration of Helsinki.6 23.9% 50.1 % 37.9) 28. general practice and former hospital records were obtained (with patient’s consent) and studied by the interviewer in addition to using the results of the structured interviews in order to ascertain diagnoses. L.4% 46. S. psychiatric coomparison group. H.and Over-Regulation of Affect Note: BPD. undifferentiated somatoform disorder.0 12.6 (9. SoD. 58 met criteria for SoD only. certified clinical psychologist/ psychotherapist). Where possible. 2008).g. All had received previous inpatient or outpatient treatment at psychiatric or somatic hospitals and were referred for specialized treatment. general health psychologists and master students in clinical psychology who were trained and supervised by AvD. middle level secondary education. highest level of education attained. No significant effects were found for sex.9 (8. After complete description of the study and procedure. somatization disorder. M.7 PC 64 28 36 36.1) 37.8 40 SoD 159 47 112 38.2 % 35.3 % 41. or a general practitioner with psychiatric experience.3 24. 120 patients met criteria for BPD only. primary and low-level secondary education. .1 24. All patients in the Eikenboom group met criteria for SoD and 16 also met criteria for BPD.8 (9. Table 1 Demographic Characteristics of the Study Groups and the Total Sample BPD N= Male Female Age M (SD) Social N T S Educ L M H 120 40 80 29. and 64 did not meet criteria for BPD or SoD and were included as a psychiatric comparison group. In the De Waard group. 113 met criteria for both BPD and SoD. and level of education on the dependent variables.4% 41. Social. a specialist in internal medicine.1 34. living together.4 BPD+SoD 129 30 99 33.7 (10.3 15. N. somatoform disorder.9 31.3 12. subjects provided written informed consent to participate.8 8. Educ. All participants had a well-documented history of somatic and/or psychiatric symptoms. T. diagnosis of BPD and SoD (i.1) 40. This study was approved by the local ethics committee. separated by death or divorce. high-level secondary education. no primary partner.1% 56..7 Total Sample 472 145 327 34.3 % 47.9 29. severe conversion and pain disorder) were confirmed by clinical interviewers (e. Table 1 presents the demographic characteristics of the four study groups and the total sample.3 (10.2 35. The diagnosis of SoD additionally was confirmed by a psychiatrist with somatic experience.5 13.8 % 60.6 % 45.2 22.5) 45.e.participated in the multi-center project “Clinical Assessment of Trauma-Related Self and Affect Dysregulation” (Van Dijke.8) 30.4 27. Next to intake according to the DSM-IV criteria.5 Chapter two 23 Differentiating Dysfunctional Under. primary relationship status. PC.

The reliability for the total scale and its subscales is good and varies between . 1999) is a semi-structured interview that contains nine sections (abandonment. we performed reliability analysis and found that the affect dysregulation sub-scale was reliable in this sample (Cronbach’s α = . An average score was calculated for each section. 1990. WHO.. The SIDES-rev was translated into Dutch and retranslated by a near-native speaker. and use of self-defeating coping to deal with distress. & Peters. 1998. 1998).a.Measures The CIDI (Composite International Diagnostic Interview section C. ever become desperate when you thought that someone you cared for was going to leave you?” The items are scored by the interviewer using a 10-point scale. 1993. the measure addresses the core components of under-regulation of affect. i. World Health Organization. frequent/intense distress. Each section contains items asking about events. and dissociation and paranoia) corresponding to the symptom clusters of BPD. self-image. & Van den Brink1998) is a comprehensive. The criterion for presence of pathological under-regulation of affect was adopted from the SIDES scoring manual (Ford & Kidd. impulsivity. each subject completed the Bermond Vorst Alexithymia Questionnaire (BVAQ.75 and . each subject completed the Dutch self-report version of the Structured Interview for Disorders of Extreme Stress Not Otherwise Specified. encapsulating two distinct second order factor groupings: cognitive dimensions (diminished ability to verbalize.85 (Vorst 24 . from criterion I. Dutch version IV. for example. standardized instrument for assessing mental disorders according to the definitions and diagnostic criteria of DSM-IV and ICD-10. 1998. (2) being unable to get over the upset for hours or not being able to stop thinking about it. 2001). 2003). 2002). Arntz. High scores represent stronger alexithymic tendencies. Smeets. “Did you. parasuicide.75). The BPDSI (Borderline Personality Disorder Severity Index. which is a Dutch forty-item questionnaire with good psychometric qualities (Vorst & Bermond. The items include: (1) often getting “quite upset over daily matters. “affect dysregulation:” 2 out of 3 items ≥ 2). relationships. Dutch version Smitten. Weaver & Clum. Revised (SIDES-rev. an adaptation of the interview which provides a sub-scale for dysregulated affect (Ford & Kidd. using drugs or harming yourself” to cope with emotional distress. emptiness. Vorst & Bermond. and analyze emotions) and affective dimensions (diminished ability to emotionalize and fantasize). therefore. October 2003). total scores were calculated by summing the section scores.e. inability to modulate or recover from distress. anger. In order to assess ‘over-regulation of affect’. indicating how often the event happened during the last three months. The CIDI has been shown to have good reliability and validity (Andrews. The SIDES self-report version has not been validated in a BPD or SoD population. Ford & Kidd. In order to assess ‘under-regulation of affect’. identify.. affect. Thus. and (3) having to “stop everything to calm down and it took all your energy” or “getting drunk. during the last three months. for inclusion a cut-off score of 20 was used (personal communication Arntz. Dutch translation Van Dijke & Van der Hart. The BPDSI has been shown to have good validity and reliability (Arntz et al. 1998). 2001).

BVAQ-cognitive factor) were explored using Pearson correlations (two-tailed).04 for BPD+SoD. with a large effect size for under-regulation of affect (over-regulation of affect . 1997) and applied to the BVAQ cognitive factor by Vorst (personal communication. 2001).and Over-Regulation of Affect RESULTS When considering the sample as a whole.017). & Parker. 25 Differentiating Dysfunctional Under. There was a statistically significant difference between all diagnostic groups: F (6.80).55.& Bermond. Finally. p<.09. to . Chapter two Statistical Analyses All statistical analyses were performed using SPSS.80]. When the results for the independent variables were considered separately. a positive value denoted “more frequent than expected” compared to all other groups. 2004).a. Wilks’ Lambda= . Logistic regression analyses with contrasts: PC groups versus all others. A negative value denoted “less frequent than expected”. Standard residuals are a way of contrast testing. under-regulation and over-regulation of affect were weakly related (r = . The cut off score for pathological alexithymia/ over-regulation of affect was adopted from the TAS-20 study (Taylor.02 for BPD.84. BPD versus SoD.27 .. Parker. Standard residual values less than -2 or greater than 2 are statistically important. 2006.11. Bagby. 1994. The cognitive factor of the BVAQ was used to assess over-regulation in order to enable comparison with previous studies (Waller & Scheidt. A reliability analysis was performed for the whole sample and the BVAQ proved to be reliable for our purposes (Cronbach’s α = . r = . September 2002). between group differences were found for affect dysregulation. The cognitive factor of the BVAQ is highly correlated with the Toronto Alexithymia Scale (TAS-20. & Taylor.88). and . to .. MANOVA was conducted to explore group differences in affect dysregulation. partial eta squared=. Associations between under-regulated and over-regulated forms of affect dysregulation (SIDES-rev I.09 for SoD. in order to determine the relative strength of the association between affect dysregulation with diagnostic subgroup membership.001.05 for PC and all were not significant [ p = . BPD versus BPD+SOD and SoD versus BPD+SoD were conducted with membership in each diagnostic group as the dependent variable and under-regulation and over-regulation of affect scores as independent variables. version 16 (SPSS Chicago). p < . cross tabulations with Chi-square tests were used to determine whether the distinct forms of affect dysregulation were represented differently among all diagnostic groups. Bagby. Group means for the continuous affect dysregulation scores (under-regulation and over-regulation) were compared using multivariate analyses of variance (MANOVAs) with diagnosis as dependent variable. The correlations within each sub-group ranged from . 930)=14.

BPD participants (and especially those diagnosed with both BPD+SoD) were most likely to report both and more under-regulation and over-regulation of affect. p = 0.43. df = 2. p < . Table 2 Affect Dysregulation Means and Continuous Scores for groups Group BPD SoD Mean (SD) BPD+SoD PC N 119 159 129 63 Under-regulation of affect 8. 465) = 26. Significant differences between all groups were found (χ2 = 67. somatoform disorder. p < 0.03.and over-regulation.14). df = 2.40.11. Using the described cut-off scores for clinical-level affect dysregulation. For all contrasts. BPD+SoD. Figure 1 shows direction of differences for over-regulation and under-regulation of affect separately for the study groups.63 (17.89) 72. partial eta-squared = .000). df = 8. and psychiatric control groups. psychiatric comparison group. under-regulation of affect F (3. p = 0.60 . Regression analyses were performed using contrast testing between groups.06 (17. borderline personality disorder.89. and 30. BPD+SoD. SoD. The results present ‘profiles’ for each disorder suggested using contrasting that PC was inversely associated with over-regulation of affect. SoD.35. The Hosmer-Lemeshow test revealed that for all contrasts the model fits the data well (PC versus all others: χ2 = 6. BPD versus SoD: χ2 = 13. SoD versus BPD+SoD: χ2 = 62.29 (1. df = 9. p < 0. df = 2. BPD versus BPD+SoD: χ2 = 6.and over. BPD versus BPD+SoD: χ2 = 1. df = 8.80. BPD+SoD. 19. BPD was associated with under-regulation of affect and comorbid BPD and SoD was associated with both under-regulation and over-regulation of affect.26 (17. df = 8.30) Over-regulation of affect 77. The results are presented in Table 3.5% reported non-clinical levels of both under.90) 70.03.07.59.regulation. 465) = 4. p = . and the psychiatric comparison groups. df = 8. the inclusion of the two independent variables improved the fit of the model significantly except for BPD versus BPD+SoD (PC versus all others: χ2 = 6.001). 28. BPD versus SoD: χ2 = 47. partial eta-squared = .000. p = 0.54) 79. SoD. p < 0.55) 26 Note: BPD. Table 2 displays the means of the continuous scores for affect dysregulation for the BPD.19 (2.02) 8. 22% reported clinically significant high levels of under-regulation only.84) 6.3% reported clinically significant high levels of over-regulation only. df = 2.83) 7.13). p = 0. SoD versus BPD+SoD: χ2 = 12.64 (2.89.9. Figure 2 presents results concerning the presence of affect dysregulation for the BPD.F (3. borderline personality disorder and somatoform disorder.2% of the total sample reported clinically significant high levels of under. PC.59.44 (1.48. The SoD group .70 (19.51.26.

and Over-Regulation of Affect Chapter two Figure 1a Group differences for under-regulation of affect Figure 1b Group differences for over-regulation of affect .27 Differentiating Dysfunctional Under.

10 1. ** p < 0.83 .99 1. (-) inversely related.91 (-) 1.Table 3 Regression Analyses using contrast testing for over-regulation and under-regulation of affect.01 1.98* (-) .01.0 % C. borderline personality disorder and somatoform disorder. somatoform disorder.97 .05.97 .99 . borderline personality disorder.00 1.001.03 1. SoD. Figure 2 Distribution of study groups for clinical levels of under-regulation and over-regulation of affect .02 1.79 1.34 . BPD.55*** .72 28 BPD versus BPD+SoD Over-regulation of affect Under-regulation of affect SoD versus BPD+SoD Over-regulation of affect Under-regulation of affect Note: * p < 0.01 1. BPD+SoD.I.54 Upper 1. psychiatric comparison group. Odds Ratio 95.99*(-) .62*** (-) . For Odds Ratio Lower PC versus all others Over-regulation of affect Under-regulation of affect BPD versus SoD Over-regulation of affect Under-regulation of affect .00 .96 .98 . PC.80 . *** p < 0.

suggesting that this combination of affect dysregulation does occur but is not typical in patients with BPD or SoD. Linehan 1993. 2004).significantly more frequently reported non-clinical levels of affect dysregulation (standard residual value = 3. 2002. Still. under-regulation of affect was not exclusively present in BPD and over-regulation was not exclusively present in SoD patients.or over-regulation. affect dysregulation.and under-regulation than the other groups. appears to be an important component of borderline personality pathology (Koeningsberg et al. In line with previous studies and consistent with study hypotheses. & Westen. Fewer than one in three patients reported experiencing both underand over-regulation. 2001. These findings are in line with those of Paivio and 29 Differentiating Dysfunctional Under. under-regulation was particularly uncommon and clinical levels of over-regulation were reported more often than for any of the other diagnostic groups (including BPD+SoD). This finding is consistent with prior research and clinical observations about alexithymia in SoD (Waller & Scheidt. there is a spectrum of both under-regulation and over-regulation of affect present in patients diagnosed with BPD and/or SoD. 2004. The results suggest that while BPD and SoD often involve affect dysregulation (Linehan. and further suggests that only a sub-set of SoD patients experience clinical levels of over-regulation of affect. when SoD occurred without BPD. Waller & Scheidt. Chapter two DISCUSSION Although all patients reported some symptoms of affect dysregulation. there is partial support for the study hypothesis that SoD would be particularly associated with over-regulation.2) or both under-regulation and over-regulation (standard residual value = -3. 2006). SoD was not consistently associated with reports of clinical levels of under. McMain et al.. except when comorbid with BPD. 1993. 2005) but is not present in every patient. Over-regulation and under-regulation of affect proved to be related yet were largely distinct. Thus.6) and more frequently reported clinical levels of both under-regulation and over-regulation of affect (standard residual value = 3. This study provided evidence that two qualitatively different forms of dysfunctional affect regulation do exist.6) than the other groups. BPD was associated with a greater likelihood of clinical and higher levels of affect dysregulation than SoD.3) than the other groups. 2006. Moreover.8) and less frequently reported clinical levels of under-regulation (standard residual value = -2. clinical levels of affect dysregulation do not appear to be present in all BPD or SoD patients. Participants diagnosed with comorbid BPD and SoD significantly less frequently reported non-clinical levels of affect dysregulation (standard residual value = -3. specifically under-regulation of affect. patients with BPD+SoD reported both significantly higher levels of under-regulation of affect and reported more frequently clinical levels of combined over. Zittel Conklin.. However. Also consistent with study hypotheses.and Over-Regulation of Affect .

Minton. Transference Focused Psychotherapy (Levy et al. modulate. Therefore. difficulty differentiating emotions.to fiveyear treatment periods with patients diagnosed with BPD incorporate emotion regulation interventions designed to address both under. and (b) under-regulation was most severe when BPD occurred in combination with SoD (almost one in four patients with SoD reported clinically significant under-regulation when BPD was also present). Mentalization Based Treatment (Bateman & Fonagy. 2006). these results indicate that there are distinct sub-groups with different types and degrees of affect dysregulation within the broad diagnostic cohorts defined by BPD and SoD and their combination.Laurent (2001). difficulty analyzing emotions and difficulty verbalizing emotions) by means of emotion recognition training (Ekman. 2006) could also contribute to the process of emotional awareness and emotional growth.as well as under-regulation with patients diagnosed with BPD may particularly warrant testing when SoD or clinically significant somatoform symptoms also are present. others. The present findings suggest that treatments such as these which address over. Clinically. who report ‘emotional blindness’ addressing the different facets of over-regulation (e. patients with BPD should be assessed for over-regulation. particularly when SoD is comorbid. 2006) assists patients in using the patient-therapist relationship and transferential (re)enactments in order to recognize. and several psychotherapy models that have shown evidence of efficacy over one. especially those with comorbid SoD. patients with SoD should be assessed for under-regulation. Dialectical Behavior Therapy teaches skills for mindfulness in order to facilitate emotion awareness. Approaches to affect regulation have been developed for patients with severe psychiatric disorders (Wolfsdorf & Zlotnick.and under-regulation of affect and that under. who observed two forms of dysfunctional affect regulation in their patients when working with emotions in psychotherapy. and Pain. (a) one in five patients with BPD also reported substantial overregulation. and their relationships (which can be considered examples of increasing the capacity for emotion modulation).and over-regulation are most likely to co-occur among patients with BPD although only in a sub-set of these patients: particularly those with comorbid SoD. Also. Ford & Russo. 2008) similarly focuses on the patient-therapist relationship to assist patients in becoming aware of their moment-to-moment state of mind (including enhanced emotion awareness) and collaboratively developing alternative ways of understanding themselves. for BPD patients. 2003) or sensory motor therapy (Ogden.. Similarly. Our findings extend this work by suggesting that there may be a third form: combined over..g. 2006). and one in six patients with SoD reported clinically significant under-regulation.and over-regulation. 2001. and develop new relational schemas with regard to states of emotional emptiness as well as distress. Although under-regulation was most associated with BPD and over-regulation with SoD. particularly when BPD is comorbid. distress tolerance and emotion regulation in order to enhance the modulation of extreme emotion states (Linehan et al. 30 .

independent instruments were used to assess each form of affect dysregulation. We attempted to quantify clinical observations and theoretical aspects of affect dysregulation using empirical data. This might be especially true for over-regulation of affect.. Due to limitations considering the burden participants could be taken upon complementary clinical interviews e. one measure encompassing features of both forms of affect dysregulation should provide additional information. cited in Clayton. This study explored the relatively new research area of affect regulation and dysregulation. Taylor.” Patients with SoD are often described as bodily focused. Moreover. as expected. Affect dysregulation has been . The severity of the psychopathology could have interfered with the validity of the self-assessment. Roth. The data were collected during an incorporated clinical assessment procedure (Van Dijke. Kaplan. because vague or diminished affective experience might be more difficult to report. 31 Differentiating Dysfunctional Under.and Over-Regulation of Affect Future Directions To overcome the limitations of using self-reports and two different measures to assess underregulation and over-regulation of affect. in order to self-report symptoms of affect dysregulation. The results served two goals: to help direct clinical diagnosis and therapy and to provide empirical data for long-term research projects. Kernberg’s structural interview for BPD (1984) or a structured alexithymia interview (TSIA. Moreover. and their cognitive style has been described as “operative thinking” (Marty & M’Uzan. patients must be aware of psychological burden and be somewhat “psychologically minded. Bagby. & Resick. 2006). SoD patients tend to attribute burden to physical complaints as opposed to psychological distress. the results from this study call for the development of a structured interview addressing affect dysregulation and associated phenomena. Van der Kolk. because they tend to attribute burden to physical complaints as opposed to psychological distress. 2004). or the interview for complex PTSD/ DESNOS (SIDES. Mandel. Parker. No standard instrument that assesses both under. therefore. Various hypotheses about the etiology of affect dysregulation and associations with other phenomena have been described. Clinical observations or (semi) structured interviews that assess affect dysregulation could provide complementary information. 2008) in a “treatment-as-usual” program for patients with persistent BPD or SoD. Pelcovitz.We found that patients with SoD reported little affect dysregulation and if so.g.and over-regulation of affect was available. Chapter two Limitations This study took place in a clinical environment (as opposed to a laboratory or an academic environment). they show little psychological mindedness. & Dickens. This could a particular problem for patients with SoD patients. Self-report measures were used to assess affect dysregulation. (1997) had to be removed. Affect dysregulation was considered to be different from affective instability: mood swings between neutral-anxious or neutral-angry or neutral-depressive. they tended to report over-regulation of affect unless BPD was comorbid.

McLean.and over-regulation of affect in the traumatic stress disorders remain to be explored. over-regulation and combined under. & Stuckless. Because some BPD and SoD patients experience significant difficulty with affect regulation. 2002). & Iversen. Orsillo. it is important that future studies assess whether these impairments interfere with their reflective awareness abilities and with their broader information processing (Ford. Our findings are consistent with prior calls for more systematic attention to over-regulation in PTSD and CPTSD research. 2005. . Schore. & Mandel. Gergely. 1996). assessment. 1992. Although emotional numbing is a hallmark symptom of PTSD (Litz. and treatment (Krystal et al.. Roth. Mandel. Pelcovitz. social cognition (Lynch et al. 2000).. Studying affect dysregulation in terms of under. and competencies critical to sociovocational functioning and independent living. Van der Kolk. specifically in the orbitofrontal cortex area that is associated with the processing of emotionally-valenced information (Berlin.and over-regulation can provide information about the mechanisms of dysregulation in these and other diagnostic cohorts of psychiatric patients. most conceptual models of PTSD and CPTSD emphasize underregulation as the primary form of affect dysregulation. Rolls. Consistent with this possibility. 2001). Desrocher.associated with psychological trauma and complex posttraumatic stress disorder (CPTSD) or disorders of extreme stress not otherwise specified (DESNOS) (Herman. BPD patients have been found to have altered brain development and function. Jurist. Van der Kolk. Our findings are consistent with treatment models that emphasize affect identification and modulation for patients diagnosed with BPD and facilitating emotional experiencing in patients with SoD. Donegan et al. The interrelationships and characteristics of under. 2005). 32 CONCLUSION By differentiating affect dysregulation into under-regulation and over-regulation of affect. Toner... 2006. 2006). Van der Kolk et al. 1997. Roth.and over-regulation of affect.and self-regulation (Fonagy. & Resick. and has been associated with affect. The results of this study suggest that considering BPD and SoD as disorders of affect regulation might be an oversimplification. this study revealed three qualitatively different forms of affect dysregulation in patients with BPD and SoD: under-regulation. including a reduced ability to identify and verbalize feelings. & Weathers. 2000). Pelcovitz. Kaloupek. 1997. 2003. & Target. Newman. Jackson. The ability to experience emotions while maintaining a sense of agency and mastery facilitates reflective function.

Chapter three Affect Dysregulation and Dissociation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Inhibitory and Excitatory Experiencing States Van Dijke. 11..J. Van Son. . Affect dysregulation and dissociation in borderline personality disorder and somatoform disorder: Differentiating inhibitory and excitatory experiencing states. M. 424-443.M. Journal of Trauma and Dissociation. A.. Bühring...G. (2010).M. Van der Heijden. J. Ford.. O.D.Van der Hart. M. P.

in this study both under-regulation and over-regulation of affect and positive and negative somatoform and psychoform dissociative experiences were assessed in borderline personality disorder (BPD) and somatoform disorder (SoD). patients with both BPD and SoD reported more psychoform (with or without somatoform) dissociative experiences. SoD patients reported more often low levels of dissociative experiences and reported fewer psychoform (with or without somatoform) dissociative experiences than other groups. Evidence was found for the existence of three qualitatively different forms of experiencing states: inhibitory experiencing states (over-regulation of affect and negative psychoform dissociation). Two forms of affect dysregulation and somatoform and psychoform dissociation were measured using self reports. Positive and negative dissociative symptoms were identified using expert opinions. there is a wide range of intensityof both somatoform and psychoform dissociative phenomena in patients with these diagnoses.ABSTRACT Introduction Despite apparent similarities little is known about how dysfunctional affect regulation and dissociation interrelate. Therefor. Conclusion Distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients. . excitatory experiencing states (under-regulation of affect and positive psychoform dissociation). Results Although both BPD and SoD can involve dissociation. Compared to the other groups. and combination of inhibitory and excitatory experiencing states commonly occurring in comorbid BPD+SoD. 34 Method BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews.

2004. pain.. Dissociation involves two parallel types of manifestations. & Westen. affect dysregulation refers to “under-regulation”: a deficiency in the capacity to modulate excitatory states of affect such that emotions become uncontrolled. Nijenhuis and colleagues (Nijenhuis. intrusions) symptoms. 2004. However.. 2004. Positive symptoms of dissociation involve intrusion symptoms. Van der Hart. hyper-alertness. Affect dysregulation in severe psychiatric disorders has been defined in two distinct ways (e.g. Bradley. Both affect dysregulation and dissociation encapsulate (sets of) mental states representing inhibitory and excitatory experiencing (Clayton. and overwhelm reasoning (Koeningberg et al. surprisingly little is known about the specific interrelations between the two psychopathological phenomena (e. Zittel Conklin. 1998) further subdivided dissociative symptoms into somatoform and psychoform dissociation. Nijenhuis. including feeling overwhelmed.g. stemming from dissociative parts re-experiencing trauma. Zittel Conklin.. 2006). expressed in intense and unmodified forms. Clinically. 2006). Steele.g. an inhibition of the ability to recognize and articulate affects that can be considered a form of “over-regulation” of emotion.. frozen. & Steele. Mental states associated with excitatory experiencing are consistent with under-regulation of affect and with the positive symptoms of dissociation. Negative symptoms of dissociation refer to apparent losses--apparent because experiences that tends not to be available to one dissociative part of the personality may actually be available to another part (Van der Hart. Nijenhuis. Nijenhuis. including appearing emotionally constricted.. & Brown. no study has systematically assessed the relationship of affect dysregulation—including both its excitatory Chapter three 35 Differentiating Inhibitory and Excitatory Experiencing States ..g. fugue states. Van Son. while under-regulation of affect. Nijenhuis et al. In the borderline personality disorder (BPD) literature. 2006). 2006). and difficulty handling intense emotion states. 2004. 2006) also involves negative (e. In literature on somatoform disorders (SoD). 2000. impulsivity. In line with Janet’s original research.. 2008). & Westen. Van Dijke. 2000. Van Dijke. Mental states associated with inhibited experiencing are consistent with over-regulation of affect and with the negative symptoms of dissociation. Somatoform dissociation includes negative symptoms (e. 1999. Van der Hart et al. 1996. 2002. Nijenhuis. amnesia) and positive (e.. negative somatoform or psychoform dissociative experiences appear to reflect inhibitory experiencing. anesthesia) and positive symptoms (e. positive somatoform or psychoform dissociative experiences appear to reflect excitatory experiencing. seizures. Psychoform dissociation (Nijenhuis. & Steele. 2006). 2004. Van Dijke.. affect dysregulation has been referred to as alexithymia (Waller & Scheidt. over-regulation of affect. Briere. e. self-harm. that is. machine-like. 2004.g. and an inability to establish close ties with others. Van der Hart. 2008).. 2005.. Van der Hart et al.INTRODUCTION Despite apparent similarities between affect dysregulation and dissociation.g.g. expressionless.

Akyuz. Van der Kolk et al. we investigated the presence and relationship between inhibitory and excitatory phenomena in patients with either BPD. 2006). comorbid BPD and SoD. However. For both groups. Research suggesting that these phenomena may help to characterize the psychopathology underlying BPD and SoD. Jackson. The ratings of psychoform dissociation were found to be higher in the non-pain group than in the pain group. Kemperman. somatization. neither overregulation of affect nor differentiating negative and positive dissociative experiences have been studied in relation to each other or in relation to under-regulated affect. & Ertem-Vehid. and Shearin (1997) studied self-injurious behavior and mood regulation in BPD patients and compared BPD patients who experienced pain during self-injury with those who did not. Bohus et al. Stiglmayr and colleagues concluded that aversive tension in BPD induces stress-related dissociative features. (2001) studied the experience of tension and dissociation in female BPD patients and found a strong correlation between duration and intensity of tension and experience of dissociative features. Russ. In reviewing the literature. Therefore. or other psychiatric disorders. Kugu.(under-regulated) and inhibitory (over-regulated)—and dissociation—including its positive and negative somatoform and psychoform features. three studies provided quantitative information on the relationship between affect dysregulation and dissociation in patients with borderline personality disorder (BPD). Overall. Conceptually and clinically. inhibitory or over-regulated affect and somatoform dissociation appear central to the symptom features of SoD. McLean. is sparse and preliminary. Öztürk. and psychoform dissociation were highly interrelated. Their results showed that under-and over-regulation of affect were correlated with psychoform dissociation and somatization. (2000) evaluated inpatient Dialectical-Behavioral Therapy for BPD and found that when patients developed skills for distress tolerance and under-regulation of affect they reported less psychoform dissociative phenomena. the results of these studies suggest a relationship between under-regulation of affect and dissociative phenomena. Desrocher. Both the under-regulated/excitatory and over-regulated/inhibitory distinction and the psychoform-somatoform distinction are particularly relevant to the two severe psychiatric disorders that are the focus of the present study. mood elevation and decreased dissociation followed self-injury. (1996) found that under-regulation of affect. and Stukless (2006) studied the relationship between affect dysregulation and dissociation in patients with reported histories of childhood sexual abuse. This study also suggested a relationship between affect dysregulation 36 . Stiglmayr et al. excitatory or under-regulated affect and psychoform dissociation appear to be prominent in BPD. and to distinguish the two disorders. Two studies have quantified the relationship between affect dysregulation and dissociation with regard to somatoform disorders. SoD. Toner. Dissociation is rarely rigorously defined in the BPD literature and not systematically explored as a contributor to the instabilities thought to underlie BPD ( ar. both somatoform and psychoform. In the DSM-IV field trial for post-traumatic stress disorder (PTSD). Similarly.

but this relationship was not directly addressed. Brown. 2005. In the present study. Rotterdam (n = 355). comorbid BPD and SoD. Schrag. or a general practitioner with psychiatric experience. . who participated in the multi-centre project “Clinical Assessment of Trauma-Related Self and Affect Dysregulation” (Van Dijke. Taken together. or other psychiatric disorders. diagnosis of BPD and SoD (i.. Chapter three 37 Differentiating Inhibitory and Excitatory Experiencing States METHODS Participants and procedure Study subjects were 472 consecutive admissions to two adult inpatient psychiatric treatment centers: Eikenboom Center for Psychosomatic Medicine. All participants had a well-documented history of somatic and/or psychiatric symptoms. 2008). undifferentiated somatoform disorder.and dissociation. this study hypotheses suggest that BPD will primarily involve underregulation of affect and positive psychoform dissociation. Utrecht (n = 117) and De Waard. & Trimble. 2004). SoD. while positive and negative forms of psychoform dissociation will be particularly prominent in BPD. All had received previous inpatient or outpatient treatment at psychiatric or somatic hospitals and were referred for specialized treatment.. Next to intake according to the DSM-IV criteria. In the present study. it is hypothesized that under-regulation of affect will be more associated with positive dissociative phenomena and over-regulation will be more associated with negative dissociative phenomena. 2005). One study has explored the interrelatedness of over-regulation and somatoform and psychoform dissociation in a non-clinical population (Clayton. clinic for personality disorders. The diagnosis of SoD additionally was confirmed by a psychiatrist with somatic expertise. The results suggested a tentative link between somatoform dissociation and over-regulation of affect. severe conversion and pain disorder) were confirmed by clinical interviewers (e. while SoD will primarily involve over-regulation of affect and negative symptoms of somatoform dissociation. although this has not been done specifically in relation to the positive as well as negative features of somatoform and psychoform dissociation. BPD and SoD have been found to be associated with affect dysregulation and dissociation (Ebner-Priemer et al. somatization disorder. certified clinical psychologist/ psychotherapist). a specialist in internal medicine. general health psychologists and master students in clinical psychology who were trained and supervised by AvD. Where possible. These questions were addressed in a large inpatient sample diagnosed with either BPD.g. it is hypothesized that positive and negative types of somatoform dissociation will be particularly prominent in SoD. general practice and former hospital records were obtained (with patient’s consent) and studied by the interviewer in addition to using the results of the structured interviews in order to ascertain diagnoses. Delta Psychiatric Center.e.

and 64 did not meet criteria for BPD or SoD and were included as a psychiatric comparison group. borderline personality disorder. no primary partner.1) 37. affect.section C. World Health Organization. self-image. middle level secondary education. 1993. separated by death or divorce.7 (10. Smeets.2 % 35.3 15. Weaver & Clum.1 % 37.All patients in the Eikenboom group met criteria for SoD and 16 also met criteria for BPD.9 29. highest level of education attained.3 (10. 113 met criteria for both BPD and SoD.6 (9.8 % 60. Measures The Composite International Diagnostic Interview (CIDI. SoD. After complete description of the study and procedure. An average score was calculated for each . & Peters.8 8. Arntz. The BPDSI (Borderline Personality Disorder Severity Index.9% 50. Social.1% 56. somatoform disorder.5 13.1 24. borderline personality disorder and somatoform disorder. Educ. indicating how often the event happened during the last three months. living together.7 PC 64 28 36 36. standardized instrument for assessing mental disorders according to the definitions and diagnostic criteria of DSM-IV and ICD-10. In the De Waard group. parasuicide.4% 46. Dutch version Smitten.2 22. relationships. The CIDI has been shown to have good reliability and validity (Andrews.6 % 45.2 35. 1998). emptiness.1 34. ever become desperate when you thought that someone you cared for was going to leave you?” The items are scored by the interviewer using a 10-point scale. PC.8 (9.4 27.4 BPD+SoD 129 30 99 33. BPD+SoD.5 38 Educ Note: BPD.8) 30. L. 120 patients met criteria for BPD only. primary and low-level secondary education.3 24. Table 1 presents the demographic characteristics of the four study groups and the total sample.9) 28.4% 41.9 (8.1) 40. and level of education on the dependent variables. This study was approved by the local ethics committee.8 40 SoD 159 47 112 38. M. Table 1 Demographic Characteristics of the Study Groups and the Total Sample BPD N= Male Female Age M (SD) Social N T S L M H 120 40 80 29. Each section contains items asking about events. impulsivity. T.6 23. primary relationship status. No significant effects were found for sex. 1990. subjects provided written informed consent to participate.0 12. WHO.5) 45.3 % 41. N. 1999) is a semi-structured interview that contains nine sections (abandonment. and dissociation and paranoia) corresponding to the symptom clusters of BPD. according to the Declaration of Helsinki.3 % 47. psychiatric coomparison group.9 31. “Did you. 58 met criteria for SoD only.3 12. high-level secondary education. for example. during the last three months. H. S. Dutch version IV. & Van den Brink1998) is a comprehensive.7 Total Sample 472 145 327 34. anger.

2006. The BVAQ is a Dutch forty-item questionnaire with good psychometric qualities (Vorst & Bermond. Somatoform dissociation was measured using the Somatoform Dissociation Questionnaire (SDQ-20. 1997) and applied to the BVAQ cognitive factor by Vorst (personal communication. relationships. test-retest reliability 0.96) and clinical validity (Ensink & Van Otterloo.95..section. 1996). In order to differentiate clinically significant scores of psychoform dissociation from normal dissociative experiences. 1998. 1989). 2001). participants completed the Bermond Vorst Alexithymia Questionnaire (BVAQ. Dutch version. 2001). The criterion for the presence of pathological underregulation of affect was adopted from the SIDES scoring manual (Ford & Kidd. total scores were calculated by summing the section scores. Dutch version Van Dijke & Van der Hart. In order to assess under-regulation of affect. for inclusion a cut-off score of 20 was used (personal communication Arntz. October 2003). Total scores were calculated by averaging the 28 item-scores. 1998. and fundamentally altered self-perceptions. In order to assess over-regulation of affect. 1994.79-0. Van der Kolk. 1986. from criterium I “affect and impulse dysregulation”. and analyzing emotions) and affective dimensions (difficulty emotionalizing and fantasizing). et al. each subject completed the self-report version of the Structured Interview for Disorders of Extreme Stress Not Otherwise Specified-revised (SIDES-Rev.80). 1998. 2004). a 20-item self-report questionnaire using 5-point Likert scales to indicate the extent to which the statements are applicable..88). Only the cognitive factor of the BVAQ was used to assess over-regulation in order to enable comparison with previous studies (Waller & Scheidt. 2001). 1990). an adaptation of the interview consisting of items formulating the sequelae of complex trauma. a 28-item selfreport questionnaire that surveys the frequency of various experiences of dissociative phenomena in the daily life of the respondents. dissociation. Bernstein & Putnam. Nijenhuis et al. Chapter three 39 Differentiating Inhibitory and Excitatory Experiencing States .91).. Psychoform dissociation was measured with the Dissociative Experiences Scale (DES. High scores represent stronger alexithymic tendencies: “diminished ability to …” The reliability for the total scale and its subscales is good and varies between 0. Dutch version. The BPDSI has been shown to have good validity and reliability (Arntz et al. which include dysregulated affect. Ford & Kidd. somatization. Reliability analysis proved this instrument reliable for these populations (Cronbach’s α = 0. a: affect dysregulation 2 out of 3 items ≥ 2). The cut-off score for pathological alexithymia/ over-regulation of affect was adopted from the TAS-20 study (Taylor.. 1989. & Taylor. Reliability analysis proved the BVAQ reliable for these populations (Cronbach’s α = 0. Vorst & Bermond. 2003). Bagby. The cognitive factor of the BVAQ is highly correlated with the Toronto Alexithymia Scale (TAS-20. 1996). Parker. and sustaining beliefs (Ford & Kidd. a cut-off score of 35 was used for inpatients. Frischholz et al. September 2002). The DES is a widely used instrument with good reliability (Cronbach’s α = 0.75 and 0. encapsulating two distinct second order factor groupings: cognitive dimensions (difficulty verbalizing. impulses. r = 0. 2002). and bodily integrity. identifying. Ensink & Van Otterloo.85 (Vorst & Bermond.

23. p < 0. entering under-regulation and over-regulation (model 1).. and model 1 plus positive and negative somatoform and psychoform scores (model 2).26. The scale has high reliability (Cronbach’s α = 0. 1998). 40 Statistical Analyses All statistical analyses were performed using SPSS.001) dissociation. 26 and SDQ-20: 3. 19.96) and good construct validity (Nijenhuis et al. Reliability analysis proved a Cronbach’s alpha of . The following contrasts were tested: PC versus the rest.88. 15. 16. A negative value denoted “less frequent than expected”.11. To this date no measure is known to us that specifically assesses positive and negative dissociation. 27 and SDQ-20: 2. version 16 (SPSS Chicago). 11. BVAQ) with positive and negative dissociation (DES. Total negative dissociation were items DES: 3.017). square root transformations were performed (Stevens. 8. More specifically. 17. Standard Residual Values (SRV) less than -2 or greater than 2 are statistically important. and Annemiek van Dijke). a positive value denoted “more frequent than expected”.Total scores are the sum of the 20 item-scores and range from 20 to 100.002) dissociation.16. 5. Although both positive and negative symptoms generated reliable scales. . Reliability analysis proved a Cronbach’s alpha of .76. 14. 6. p < 0. 4. we consider the research on positive and negative dissociative symptoms ‘work-in-progress’. 18. SDQ) were explored using Pearson correlations (two-tailed). BPD+SOD. 11. we used a cut off score of 8. SoD. 20. 22. 2002). The items from the DES and SDQ-20 were evaluated by three experts in the positive and negative dissociative symptoms field (Onno van der Hart. 12. 7. In order to differentiate clinically significant somatoform dissociation from normal dissociative experiences. 5. Due to non-normality of the dissociation variables. Associations between under-regulated and over-regulated forms of affect dysregulation (SIDES-rev. 15. 10. 4. 12. 9. 10. 25. Standard residuals are a way of contrast testing. Ellert Nijenhuis. BPD versus SoD. cross tabulations with Chi-square tests were used to determine whether the distinct forms of dissociation were represented differently among the diagnostic groups. 13. 13. 6. Under-regulation and over-regulation were weakly related to each other (r = 0. BPD+SoD versus BPD.37.000) and somatoform (r = 0. based on the SDQ-5 scores. p < 0. & PC). Sequential regression analyses were conducted. 16. and BPD+SoD versus SoD. Group means for the continuous dissociation scores were compared using multivariate analyses of variance (MANOVAs) with diagnosis as dependent variable. 8. Total positive dissociation were items DES: 7.19. 1996. Finally. RESULTS When considering the sample as a whole (BPD.001) and somatoform (r = 0. Over-regulation was weakly related to psychoform (r = 0. 18. under-regulation of affect was moderately to strongly related to psychoform (r = 0. p< 0. 17. p < 0.

05) to positive and negative somatoform dissociation.001) and negative psychoform dissociation (r = 0.001) and negative psychoform dissociation (r = 0. all statistically significant p < 0. p < 0.002).and over-regulation were unrelated (p > 0. Over-regulation was weakly related to positive psychoform (r = 0.52).15. demonstrating that the positive and negative forms of both somatoform and psychoform dissociation were almost perfectly correlated ( r = .43 0. p < 0.82-. Table 2 Pearson Correlations on Transformed Negative and Positive Dissociation Scores Positive somatoform dissociation Negative somatoform dissociation Positive somatoform dissociation Negative psychoform dissociation 0.99) and that all forms of somatoform and psychoform dissociation were moderately interrelated across the two types of dissociation (r = .39-. p < 0.001. Table 2 shows the Pearson product moment correlations between negative and positive somatoform dissociative and psychoform dissociative phenomena. Figure 1a Group differences for inhibitory and excitatory experiencing for psychoform dissociation .42 Chapter three 41 Differentiating Inhibitory and Excitatory Experiencing States 0.42.15.39 0.99 Negative psychoform dissociation 0. Under.under-regulation was moderately to strongly related to positive psychoform (r = 0.46.52 Positive psychoform dissociation 0.001). p < 0.82 Note: two-tailed Pearson correlations. N = 471 for analyses with psychoform dissociation due to one case with missing data.

There was a statistically significant difference between all diagnostic groups: F (18. Wilks’ Lambda = 0. and negative and positive psychoform dissociation. SDQ-20 and SDQ-5 for the BPD. BPD+SoD. partial eta squared = 0. with large effect sizes for under-regulation of affect. and psychiatric comparison groups.91. BPD participants (and especially those diagnosed with both BPD+SoD) were most likely to report inhibitory and excitatory states of experiencing as presented in figure 1. SoD. DES.MANOVA was conducted to explore group differences in dimensions of inhibitory and excitatory experiencing (positive and negative dissociation and affect dysregulation). p = 0.72. Table 4 displays the means of the continuous scores on the measures of positive and negative dissociation and affect dysregulation. 42 Figure 1b Group differences for inhibitory and excitatory experiencing for somatoform dissociation Figure 1c Group differences for inhibitory experiencing for affect dysregulation . between group differences were found for all forms of dissociation and affect dysregulation (Table 3).001.10. When the results for the independent variables were considered separately. 1302) = 8.

. SoD↔BPD+SoD: χ2 = 96.03 .12 33. BPD↔BPD+SoD: χ2 = 11.43 Differentiating Inhibitory and Excitatory Experiencing States Chapter three Figure 1d Group differences for excitatory experiencing for affect dysregulation Table 3 Between group differences for dissociation and affect dysregulation F(3.18 .14 Sequential regression analyses were performed using contrasts to assess the relative strength of inhibitory and excitatory experiencing phenomena with the presence of BPD. df = 8. df = 8. BPD↔BPD+SoD: χ2 = 7. df = 8.81.18.21 . p = 0. The results are presented in Table 5.42.54.43 4. BPD↔SoD: χ2 = 8.3 5.23. df = 6.03 .25.9 26. the inclusion of all inhibitory and excitatory experiencing phenomena (model 2) improved the fit of the model significantly (PC↔the rest: χ2 = 32.14 . For all contrasts except for BPD versus BPD+SoD. SoD. df = 6. p < 0.16 Partial eta-squared .78. p = 0. BPD↔SoD: χ2 = 75. p = 0.72. SoD↔BPD+SoD: χ2 = 17. p < 0.No significant differences were found for inhibitory and excitatory regulation strategies between the BPD groups and the BPD+SoD group.03).03 . p < 0. or other psychiatric disorders.000.88. df = 6. p < 0. df = 6. p = 0.86.37.000. df = 8.000). BPD+SOD.47 4. 465) Negative psychoform dissociation Negative somatoform dissociation Positive psychoform dissociation Positive somatoform dissociation Over-regulation of affect Under-regulation of affect 24. The Hosmer-Lemeshow test revealed that for all dependent variables model 2 fits the data well (PC↔the rest: χ2 = 10.

62) 6.32 (7.86) Positive psychoform dissociation Positive somatoform dissociation Overregulation of affect Underregulation of affect Psychoform dissociation DES Somatoform dissociation SDQ20 Somatoform dissociation SDQ-5 44 Group Negative psychoform dissociation BPD N= 119 14.64 (2. psychiatric comparison group.95) 1.94) 13.82 (5.77) 70.30) 11. borderline personality disorder and somatoform disorder.48) 1.04 (15.33 (9.89) 24.12) 1.54) 13.98 (8.34) 10.71) 27.25 (14.41) 8.57) 77.46) 72.27 (11.38 (1.26 (17.18 (2.37) 27.25 (10.84 (1.81 (1.60) Note: numbers are not transformed.74) 30.02) 8.28 (8.61 (1.04) 1.56 (9.16) Mean (SD) SoD N= 158 7. BPD. .29 (1.55) 30.79 (8. somatoform disorder.00 (8.32 (8. borderline personality disorder.83) 7.11) 24.12) PC N= 63 7.78 (11.27 (2.37 (8.49 (1.22) 10.68) 6. PC.06 (17.83 (2.19 (2.23) 79.Table 4 Means and SD for Positive and Negative Dissociation and Affect Dysregulation and DES.44 (1. BPD+SoD.38 (1.99) 24.01) BPD+SoD N= 129 17.77 (17.10 (1.19) 8. SDQ-20 & SDQ-5 for study groups Negative somatoform dissociation 24.26 (5. SoD.25) 6.51) 27.70 (19.40 (1.90) 13.91) 7.84) 6.56 (3.

SRV = 2.02 . ** p < 0. BPD+SoD.83 .91* 1.53 .02 .98 . The SoD group was significantly more likely to report low levels of dissociation (standard risidual value.0 % C.15** 1. *** p < 0.86 .91 .96 9. borderline personality disorder. p < 0.03 1.29 1.001).16. less likely to report high levels of psychoform dissociation (SRV = -2. Figure 2 presents the distribution of cases reporting psychoform and somatoform dissociation for the BPD.94 .86 1.96 1.60 .4) than were the BPD. and 68.00 .4). and psychiatric comparison groups. df = 9.2% reported low levels of both psychoform or somatoform dissociation.85 . For Odds Ratio lower PC versus the rest Over-regulation of affect Under-regulation of affect negative psychoform dissociation negative somatoform dissociation positive psychoform dissociation positive somatoform dissociation BPD versus SoD Over-regulation of affect Under-regulation of affect negative psychoform dissociation negative somatoform dissociation positive psychoform dissociation positive somatoform dissociation BPD versus BPD+SoD Over-regulation of affect Under-regulation of affect negative psychoform dissociation negative somatoform dissociation positive psychoform dissociation positive somatoform dissociation SoD versus BPD+SoD Over-regulation of affect Under-regulation of affect negative psychoform dissociation negative somatoform dissociation positive psychoform dissociation positive somatoform dissociation .79 1.98 . Using the described cut-off scores.39*** 1.56 .87** 3.56 .74 .00 1.97 . PC. SoD. italic numbers indicate inverse relations.71* . somatoform disorder.05 1.99 1. When comparing the groups significant differences were found (χ2 = 57.77 1.01 1.76 .181 .21 .90 Chapter three 45 Differentiating Inhibitory and Excitatory Experiencing States Note: * p < 0.11 1.84 1.00 . SoD. borderline personality disorder and somatoform disorder.94 .I. Participants diagnosed with BPD+SoD were significantly less likely to report low levels of .85 .22 1.99 . 5.00 1.7% reported psychoform dissociation only.03 1.02 1.92 1.89** 1.7% of the total sample reported high levels of psychoform and somatoform dissociation.17 2.Table 5 Sequential Regression Analyses for inhibitory and excitatory experiencing phenomena using contrast testing for model 2 N=469 Odds Ratio 95.99 .99*** . psychiatric comparison group.44 .87 .07 . and psychiatric comparison groups.10 .93 .53* 1.052 .97 .42* .49 1.99 1.01 1.25 3.30 upper 1.3% reported somatoform dissociation only. BPD+SoD.46 . BPD+SoD. 9.11 .15 1.001. 16.63 1.3).98 3.97 . and less likely to report high levels of both psychoform and somatoform dissociation (SRV = -3.01.05. BPD.95 .

46 Figure 2. Thus.dissociation (SRV = -2. & Westen. stressrelated” dissociation linked to “paranoid ideation”. psychoform dissociation may play a greater role in BPD than represented in the DSM-IV’s single feature of.8) than were the other groups.2). and were more likely to report high levels of both psychoform and somatoform dissociation (SRV = 3. While the chronicity and periodicity of dissociation were not assessed in the present study.5). or high levels of psychoform dissociation only (SRV = 2. Distribution of levels of psychoform and/ or somatoform dissociation for study groups DISCUSSION Complementary to previous studies and consistent with study hypotheses. “severe” but “transient. . BPD was found to involve substantial positive psychoform dissociation and under-regulation of affect (Zittel Conklin. 2006). 2005. the pathological levels of psychoform dissociation endorsed by patients with BPD suggest that psychoform dissociation may be more than transient.

psychoform dissociation. Study findings suggest that two qualitatively different forms of psychoform and somatoform dissociation do exist (Nijenhuis et al. psychoform and somatoform dissociation were frequently reported. Chapter three 47 Differentiating Inhibitory and Excitatory Experiencing States Limitations A primary limitation is that comorbid dissociative disorder and/or (complex) PTSD cannot be ruled out for the the BPD+SoD sub-group that reported both high levels of psychoform and somatoform dissociation. However. psychoform dissociation was uncommon and somatoform dissociation was more often reported. As SoD patients become more aware of their somatosensory and emotional experiences in psychotherapy they may become more able to report dissociative symptoms.. It is possible that the diminished capacity to self-reflect resulted in decreased scores on. primarily those with comorbid BPD. SoD in the absence of BPD was most strongly associated with negative somatoform dissociation and inversely with under-regulation of affect. Infrequent reports of dissociation by SoD patients may reflect under-reporting consistent with the clinical presentation of la belle indifférence. Van der Hart et al. while both positive and negative (inhibitory) forms of dissociation were associated with BPD when comorbid with SoD. it appears that only a sub-set of SoD patients. In particular. the inhibitory dimension (over-regulation and negative dissociative experiences). Our data provide more support for the hypothesis that positive (excitatory) states of dissociation are associated with BPD. consistent with study hypotheses and prior research and clinical observations (Nijenhuis. 2006). Positive somatoform dissociation best characterized psychiatric patients with neither BPD nor SoD. because interviews assessing PTSD and/or dissociative disorders were not included in order to minimize participant burden. As hypothesized. at the beginning of treatment patients with SoD patients are less able to self-reflect and they tend to attribute psychological burden . A second limitation was that self-report measures were used to assess affect dysregulation and dissociation. 2004. For comorbid BPD and SoD. suggesting that negative somatoform symptoms—and not positive somatoform symptoms. and interrelations in. Van Dijke and colleagues (in press) found that comorbid BPD and SoD also was associated with both over-regulation and under-regulation of affect. 2004). 2004..For SoD. or affect dysregulation—may be a hallmark of SoD distinct from the dysregulated states involved in BPD. Physical health complaints consistent with positive somatoform dissociation are common co-occurrences in the presentation of psychiatric disorders. potentially reflecting either generalized distress or the adverse health impact associated with chronic poor mental health rather than specifically dissociative pathology. report severe somatoform dissociation. 2000. The constellation of somatoform dissociation and over-regulation of affect may be a feature of the more complex SoD-BPD comorbidity rather than a characteristic of SoD per se.

is a next critical next step. exposure to psychological trauma or more activated dissociative symptoms (Ross. McLean. excitatory.. Future Directions Affect dysregulation and dissociation have been associated with psychological trauma and complex PTSD (Herman. Thus. Over-regulation of affect and negative psychoform dissociation.to physical complaints. The combination of inhibitory and excitatory dissociative states. Although both BPD and SoD can involve dissociation (Bohus et al. and PTSD. Toner. Nijenhuis et al. 1997). & Mandel. can be understood as inhibitory dissociative states. . Stiglmayr et al. 1997. Van der Hart et al. assessment of positive and negative somatoform and psychoform dissociation may have utility in characterizing clinical and phenomenological features of BPD and SoD... Desrocher. Jackson. & Resick. The interrelations and characteristics of under-regulation and over-regulation of affect and psychoform and somatoform dissociation in traumatic stress related disorders (Scoboria. Dissociation is rarely rigorously defined in the BPD literature and not systematically explored as a contributor to the instabilities thought to underlie BPD. & Lin.. BPD traits in patients with severe dissociative disorders have been viewed either as a co-morbidity ( ar et al. Pelcovitz. Under-regulation of affect and positive psychoform dissociation. Newman. Van der Kolk et al. & Stuckless. clinical observations or (semi) structured interviews that assess affect dysregulation and dissociation could provide complementary information. Ford. 1997. and more severe. In the dissociative disorders literature. Therefore. Our findings contribute to the growing body of research suggesting a need for more systematic differentiation between under-regulation and over-regulation of affect (Van Dijke. commonly occurred in comorbid BPD+SoD. dissociative disorders. commonly occurring in BPD.. Frisman. Zlotnick et al. 2006. can be understood as excitatory dissociative states. 2008) and more systematic differentiation between psychoform and somatoform dissociation (e. 48 CONCLUSION We found evidence for the existence of three qualitatively different forms of dissociative dysregulation: inhibitory. assessing inhibitory and excitatory experiencing in relation trauma history among individuals with BPD. 2008) and DSM-IV dissociative disorders remain to be explored. Van der Kolk. 1992. 1996. Mandel. Pelcovitz.. Roth. alternatively. or. 2004. 1997). and combined inhibitory and excitatory states. 2006). 2000. commonly occurring in SoD. 2006). 2001). as a relatively non-specific set of instabilities that result from more.g. Therefore. Van der Kolk. Roth. and their comorbid combinations.. there is a wide range of intensity of both somatoform and psychoform dissociative phenomena in patients with these diagnoses..

A. European Journal of Psychotraumatology.Chapter four Childhood Traumatization by Primary Caretaker and Affect Dysregulation in Patients with Borderline Personality Disorder and/or Somatoform Disorder Van Dijke.M. Childhood traumatization by primary caretaker and affect dysregulation in patients with borderline personality disorder and/or somatoform disorder. & Bühring. J. P. 2. Van der Heijden. 5628 . (2011)..D. O.J.M.. M.v2i0.G.. Van Son. Ford.. Van der Hart. M.3402/ejpt.DOI: 10..5628 .

using the Bermond-Vorst Alexithymia Questionnaire (BVAQ).and over-regulation of affect depending on the type of traumatic exposure. Prior studies suggest a clear relationship between early childhood attachment-related psychological trauma and affect dysregulation. the Self-Rating Inventory for Posttraumatic Stress Disorder (SRIP). and the Traumatic Experiences Checklist (TEC). Over-regulation of affect was associated with physical TPC. and differentially associated with under. . Results Almost two-thirds of participants reported having experienced childhood TPC.ABSTRACT Introduction Affect regulation is often compromised as a result of early life interpersonal traumatization and disruption in caregiving relationships like in situations where the caretaker is emotionally. 50 Methods We evaluated the relationship of retrospectively recalled childhood traumatization-by-primary-caretaker(s) (TPC) and affect dysregulation in 472 adult psychiatric patients diagnosed with borderline personality disorder (BPD). both BPD and SoD. Conclusion Childhood trauma-by-primary-caretaker is prevalent among psychiatric patients. particularly those with BPD. somatoform disorder (SoD). Under-regulation of affect was associated with emotional TPC and TPC occurring in developmental epoch 0-6 years old. sexually or physically abusing the child. or disorders other than BPD or SoD. the Dutch self-report version of the Structured Interview for Disorders of Extreme Stress (SIDES-rev-NL). ranging from approximately 50% of patients with SoD or other psychiatric disorders to more than 75% of patients with comorbid BPD+SoD.

2005. Albach.. 2005. Moormann. 2008. Bermond. Bermond. Sifneos. Polcari. 2006. & Gleaves.. 2004. 1973). 2011) and in SoD and BPD (Van Dijke. over-regulation (but not under-regulation) mediated the relationship between child sexual abuse status and distress. Under-regulation of affect has been shown to be a common and potentially severe sequela of childhood sexual (Carey. & McGreenery. Ford. are at the heart of disturbances stemming from childhood victimization (Cook et al.g. and include extremely intense affective distress (e. Ford et al. expressed in intense and unmodified forms. & Laurent. 2005. 2010. affect dysregulation has been referred to as alexithymia (Waller & Scheidt. Albach.. 1994). Taylor. over-regulation of affect may represent a sub-type that is associated with negative symptoms of somatoform and psychoform dissociation (e. Walker. & Van Dorp. DePrince. Zittel Conklin. Moormann. affect dysregulation refers to a deficiency in the capacity to modulate affect such that emotions become uncontrolled. Paivio. & Pettit. Ford. 2005). Lochman. physical (Dodge. 2008.. generally understood as ‘no words for feelings. alexithymia also tends to involve a suppression or numbing of affect that may be considered a form of over-regulation of affect. impulsivity. and overwhelm reasoning (Koeningberg et al. Moormann. & Van Dijke. Affective disruptions. 2001). 1997. Bradley. 1997. 2001. For example. especially when this involves a caretaker (Freyd. Marx and Sloan (2002) found that among survivors of child sexual abuse. Van der Hart et al. Van Dijke. aggression). 2010). In the borderline personality disorder (BPD) literature. Lanius et al. & Albach. In the somatoform disorder (SoD) literature. & Westen. Rossouw. Chapter four 51 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation . 2010). Samson....Alexithymia.g. Greenberg. (c) pensée opératoire.. Adults who have experienced childhood victimization consistently are found to be at risk for problems with under-regulation of affect. 2006). & Stein. Paivio & Laurent.g. and (d) limited imaginal capacity (e. In addition to involving an inhibition of the cognitive capacity to differentiate and articulate affects.g. et al. Putnam. Zittel Conklin & Westen. Seedat.INTRODUCTION Affect dysregulation has been defined in two distinct ways (Paivio & Laurent. However. Teicher. Alexithymia has also been shown to be associated with a history of childhood abuse (Bermond.. 2001. Bagby. Harnish. including under-regulation and over-regulation of affect. (b) difficulty describing emotions to others. & Parker. 2008. indicating that over-regulation also may be influential in the development of psychological symptoms in child sexual abuse survivors.’ encompasses: (a) difficulty identifying emotions. & Bolger. and emotional (Goldsmith & Freyd. 2003). 2001).These problems have been described as under-regulation of affect. Van Dijke et al.. 2010.. 2000). 2006) abuse. Bates. 2007. over-regulation and under-regulation of affect were significantly related to psychological distress. 2004). overwhelming rage or fear ) and affectively-driven behavioral disinhibition (e. Van Dijke. but over-regulation of affect also may be a clinically important sequela of childhood interpersonal trauma. Both in PTSD (Lanius et al. 2002..

In addition. & Steele. Instead of modulating extreme levels of stimulation and arousal. Keijsers. the infant must devote most or all of their available biological and affective resources to withstand this state of distress and dysregulation (Tronick & Weinberg. 2005. & Moene.. Childhood traumatization for which the primary caretaker was the agent has been hypothesized to have special importance in the etiology of severe psychiatric disorders (Allen. 2005) and dissociative disorders (e.g. & Moene. However. Näring. Van der Hart. Until these states subside. 2006). Akyuz. Ozturk. 2007). Keijsers. sexual. intense negative states can persist and be experienced by the infant as unmanageable. the caretaker might provide insufficient protection against other potential abusers of the child (Lieberman. Lieberman & Amaya-Jackson. Näring. 2007). Hoogduin. 2005). Therefore. Roelofs. the present study investigated the relationship of childhood victimization and both forms of affect dysregulation in adults diagnosed with BPD. and... Schrag.. it may result in persistent problems with under. 2002) and SoD (Brown. Nijenhuis. Sar & Ross. 2007.Childhood traumatization is known to be associated with psychiatric disorders such as BPD (Yen et al.. Zanarini. If interactive repair from a caretaker is not available or responsive to the infant. Caretaker-caused traumatic stressors are likely to occur in and contribute to result in a relational growth-inhibiting early environment in which caretakers not only play less with the infant but also evoke stress (in the case of an abusive caretaker) or fail to protect the child from post-traumatic states of enduring negative affect (Fonagy et al.g.. when this persists in early development. the combination of the psychobiological challenge posed by traumatic stressors and the absence of consistent and effective co-regulation by a responsive available caretaker might compromise the child’s capacity to regulate excessive levels of high and/or low arousal negative affect. 2007. the infant and caretaker tend to experience high levels of arousal episodically when abuse has occurred and/or low levels of arousal when neglect has occurred. relatively little is known about how child abuse contributes to the etiology of these psychiatric disorders (Verdurmen et al. the caretaker shows minimal or unpredictable participation in the various types of arousal regulating processes (Lyons-Ruth et al. 2004. Kugu. Van der Kolk. 2006) and dissociative disorders ( ar. 1997). The caretaker also often is inaccessible and reacts unattuned and/or with rejection to the infants’ expressions of emotions and stress. Yonge. Therefore. 52 . and comorbid BPD and SoD. Teicher et al. 2001). 2002. 2006. & Ertem-Vehid. & Frankenburg. Kruger. 1996). SoD. 2002. Thus.. Roelofs. 2002). and emotional abuse have been hypothesized to be important etiological contributors to BPD (Bradley et al. Although contemporary researchers consider the causal association between child abuse and psychiatric disorders to be an oversimplification (e. & Trimble. physical...or over-regulation of affect in adulthood. 2002). Hoogduin. Lieberman. One possible factor contributing to the association of child abuse with subsequent BPD and SoD is affect dysregulation. 2005) and SoD (Brown et al.

early childhood (ages 0-6 years old). According to the DSM-IV criteria (APA. 2000). The diagnosis of SoD additionally was confirmed by a psychiatrist with somatic experience. All had received previous inpatient or outpatient treatment at psychiatric or somatic hospitals and . Therefore. Pettit.e. We hypothesized that trauma by a primary caretaker would be associated with particularly severe under-regulation of affect in adults diagnosed with BPD and over-regulation of affect in adults diagnosed with SoD. 2006. 2008). Altrecht Utrecht (N = 117) and De Waard.Although theory and research have emphasized the adverse impact of caretaker-related abuse that occurs in the earliest years of development.. Rotterdam (N = 355) who participated in the multi-center project “Clinical Assessment of Trauma-Related Self and Affect Dysregulation” (Van Dijke. in the present study. compared to in middle-childhood or adolescence. undifferentiated somatoform disorder. However. Prospective (Dodge. somatization disorder. We also hypothesized that these relationships would be strongest when trauma by a primary caretaker occurred during early childhood. and sexual abuse have found evidence of deleterious effects on functioning. Chapter four 53 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation METHODS Participants and procedure Participants were 472 consecutive admissions to two adult treatment centers. Where possible. Zinzow et al. severe conversion and pain disorder) were confirmed by clinical interviewers (general health psychologists and master students in clinical psychology who were trained and supervised by the first author. a certified clinical psychologist/clinical neuropsychologist). abuse or neglect by primary caretakers that occurs later in childhood or adolescence also may have detrimental effects. physical. Delta Psychiatric Center. or a general practitioner with psychiatric experience. and adolescence (ages 13-18 years old).. trauma by a primary caretaker is assessed in each of three developmental epochs. Eikenboom Center for Psychosomatic Medicine. mental health. and health in the aftermath of abuse in the school years and adolescence. Bates. & Valente. diagnoses of BPD and SoD (i. All participants had a well-documented history of somatic and/or psychiatric symptoms. 2009) studies of emotional. a specialist in internal medicine.. middle childhood (ages 7-12 years old). general practice and former hospital records were obtained (with patient’s consent) and studied by the interviewer in addition to using the results of the structured interviews in order to ascertain diagnoses. studies that systematically examined the relationship between a history of exposure to traumatic stressors for which a primary caretaker is the agent at differing developmental epochs with psychiatric and psychosocial morbidity were not found. 1995) and retrospective (Teicher et al. Centre for Personality Disorders.

1993.9 31. Dutch version IV. 1990. 11 items. self-report measures were administered under supervision of formerly described interviewers. PC.5 13. 1998).9 29. primary relationship status. World Health Organization. highest level of education attained.8 % 60. Table 1 presents the demographic characteristics of the four study groups and the total sample.3 (10. Self-image.3 24. high-level secondary education. S.5) 45.1 24. Affect. Relationships. participants provided written informed consent to participate.1) 40. & Van den Brink.6 23.4 27.2 % 35. 4 items.9) 28.9 (8. Educ.2 35. N.8) 30.8 (9. living together. indicating how often the event happened during the last three months. 8 items. “Did you.7 Total Sample 472 145 327 34. L. for example. Anger. Dutch version Smitten. no primary partner.3 12. An average score was calculated for each . standardized instrument for assessing mental disorders according to the definitions and diagnostic criteria of DSM-IV and ICD-10.3 % 41.6 % 45. 6 items. Smeets. middle level secondary education. and Dissociation / Paranoia. 7 items.1% 56. Social. Emptiness.8 40 SoD 159 47 112 38. The Borderline Personality Disorder Severity Index (BPDSI. 54 Table 1 Demographic Characteristics of the Study Groups and the Total Sample BPD N= Male Female Age M (SD) Social N T S L M H 120 40 80 29. Next. M. separated by death or divorce. SoD. primary and low-level secondary education. 8 items) corresponding to the symptom clusters of BPD.6 (9. borderline personality disorder. Measures The Composite International Diagnostic Interview.8 8.7 (10. WHO. 1998) is a comprehensive. somatoform disorder.7 PC 64 28 36 36. section C (CIDI.9% 50. psychiatric coomparison group.1 % 37.1) 37.4 BPD+SoD 129 30 99 33. borderline personality disorder and somatoform disorder.4% 41. Each section contains items asking about events.were referred for specialized treatment.1 34.0 12. After complete description of the study and procedure. This study was approved by the local ethics committee. H. during the last three months. Impulsivity.2 22. 8 items. according to the Declaration of Helsinki. BPD+SoD. T.4% 46. Parasuicide.3 15.3 % 47. Weaver & Clum. 1999) is a semi-structured interview that contains nine sections and 70 items (Abandonment.5 Educ Note: BPD. No significant differences were found between the diagnostic sub-groups in the distribution of genders or levels of education. 13 items. ever become desperate when you thought that someone you cared for was going to leave you?” The items are scored by the interviewer using a 10-point scale. 5 items. The CIDI has been shown to have good reliability and validity (Andrews & Peters. Arntz.

total scores were calculated by summing the section scores. Vorst & Bermond. an adaptation of the interview which provides a sub-scale for dysregulated affect (Ford & Kidd. The reliability for the total scale and its subscales is good and varies between .section.88).e. 2006.80). 2004). The SIDES-rev was translated into Dutch and retranslated by a near-native speaker (Cronbach’s α = . each subject completed the Bermond Vorst Alexithymia Questionnaire (BVAQ. and (3) having to “stop everything to calm down and it took all your energy” or “getting drunk. Three specific developmental epochs were considered in the present study (age 0-6 years. The cognitive factor of the BVAQ was used to assess over-regulation in order to enable comparison with previous studies (Waller & Scheidt. frequent/intense distress. using drugs or harming yourself” to cope with emotional distress. the measure addresses the core components of under-regulation of affect. and use of self-defeating coping to deal with distress. r = . (2) being unable to get over the upset for hours or not being able to stop thinking about it. Nijenhuis. i. 1998. Parker. encapsulating two distinct second order factor groupings: cognitive dimensions ( diminished ability to verbalize. The items include: (1) often getting “quite upset” over daily matters. with 100% agreement. The cognitive factor of the BVAQ is highly correlated with the Toronto Alexithymia Scale (TAS-20. 2001). 1997) and were used for categorical analyses. The cut off score for pathological alexithymia/ over-regulation of affect of the BVAQ cognitive factor is in agreement with the cut off scores used in TAS-20 studies (Taylor. 2001). 1998. In order to assess ‘over-regulation of affect’.75). from criterion I. High scores represent stronger alexithymic tendencies. 2003). The BPDSI has been shown to have good validity and reliability (Arntz et al..75 and . Ford & Kidd. identify. Bagby. a retrospective self-report questionnaire concerning adverse experiences and potential traumatic events. Reports of traumatic experiences were confirmed by close relatives in a sub-sample of Delta Psychiatric Centre participants. & Parker. and age 13-18 years) and only events that Chapter four 55 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation .. inability to modulate or recover from distress. Bagby. each subject completed the Dutch selfreport version of the Structured Interview for Disorders of Extreme Stress Not Otherwise Specified. The criterion for presence of pathological underregulation of affect and categorical analyses was adopted from the SIDES scoring manual (Ford & Kidd. 2002). 1994. & Taylor. Revised (SIDES-rev. 2001). which is a Dutch forty-item questionnaire with good psychometric qualities (Vorst & Bermond. and analyze emotions) and affective dimensions (diminished ability to emotionalize and fantasize). Participants stated for each item at what age this first happened. Dutch version. Dutch translation Van Dijke & Van der Hart. In order to assess ‘under-regulation of affect’. A reliability analysis was performed for the whole sample and the BVAQ proved to be reliable for our purposes (Cronbach’s α = . 1998). Van der Hart. age 7-12 years.a. “affect dysregulation:” 2 out of 3 items rated with severity ≥ 2). & Kruger. for inclusion and categorical analyses a cut-off score of 20 was used.85 (Vorst & Bermond. Thus. 2002). Reports of potentially traumatic events were collected using the Traumatic Experiences Checklist (TEC.

cross-tabulations with standard residuals were performed. & Van der Ploeg.and over-regulation of affect variables. 7-12. physical. Hovens. et al. TPC-types. 2010) could be accounted for by the severity or epoch of TPC. RESULTS Almost two-thirds (63. a multivariate analysis of covariance (MANCOVA) was conducted on scores for over-regulation and under-regulation of affect. 2002). Klaarenbeek. Bramsen. PTSD was assessed with a sub-sample of patients from the Delta PC study site (N=138) using Self-Rating Inventory for Post-traumatic Stress Disorder (SRIP. A total score is calculated by adding all scores. A multivariate analysis of variance (MANOVA) was performed to identify diagnostic group differences on severity scores for TPC and the reporting of TPC in three developmental epochs (0-6. This sub-sample did not differ significantly from the total sample on age. in order to determine if differences between the diagnostic groups in affect regulation (Van Dijke. All items are scored on a 4-point rating scale with anchors of 1: not at all and 4: very much.. Scores for the subscales of Intrusion. & Rivero. Further. and sexual) of potentially traumatizing events caused by a primary caretaker (TPC). 2000). The sequence of the items does not follow DSM-IV but has been randomized. BPD+SoD. 1994).directly involved a primary caretaker were used to identify the presence of three types (emotional. For categorical analyses cut off scores computed as mentioned in the measures section were applied. Pearson product moment correlations were calculated for the whole sample in order to describe the bivariate relationships among affect dysregulation (under-regulation and over-regulation). The TEC has been shown to have good reliability and validity among psychiatric outpatients (Nijenhuis et al. and psychiatric controls).6%) of participants reported at least one instance of traumatizationby-a-primary-caretaker. a DSM – IV diagnosis can be calculated by using an algorithm (Hovens. Van der Ploeg. Avoidance. indicating intensities.. Ford. SoD. Bramsen. and Hyper-arousal can be calculated by adding the scores on the relevant items. and group. To compare the likelihood of reporting TPC and under-regulation and over-regulation for each diagnostic cohort (BPD. For categorical assessment epochs in which the traumatic event first occurred was used in categorical analyses. gender. Finally. physical. and 13-18 years old). 56 Statistical Analyses All analyses were performed using SPSS. The relationships generally were . Table 2 presents the bivariate correlations between the trauma history and under. This inventory has 22 items reflecting the 17 symptoms from DSM-IV. version 16 (SPSS Chicago). and developmental epochs. with diagnostic group as the independent variable and severity of sexual. and sexual TPC and the occurrence of TPC in early childhood (ages 0-6 years old) as covariates.

31. 920) = 13. Results of the MANCOVA comparing the four diagnostic groups on the affect regulation scores while controlling for sexual. The MANOVA exploring group differences in the severity of each TPC-type.05.41. Table 2. and for over-regulation with total SRIP (r = . p < . developmental epoch 13-18 years. SoD. Approximately 50% of the SoD and psychiatric control participants reported a history of TPC. developmental epoch 7-12 years.02 .01 Table 3 presents the results from cross-tabulation analyses of the likelihood of reporting TPC for the BPD. On a dimensional level only associations for under-regulation of affect with total SRIP proved significant (r = . p <.05). p <. Under-regulation levels differed between the diagnostic sub-groups after controlling for the effect of trauma history. with a large effect .physical. analyses were repeated. Wilks’ Lambda = .000).27. and psychiatric control groups. with statistically significant correlations only between physical TPC and overregulation of affect. For a subsample of the patients meeting DSM IV-TR criteria for PTSD. physical. All effect sizes were small (see Table 4).001.13. and the two types of affect dysregulation resulted in a statistically significant difference overall: F (24. between group differences were found for emotional. developmental epochs.14** . p < . p < .17.05 .6 years.34. When the results for the dependent variables were considered separately.000). and adolescent-epoch caretaker traumatization and emotional TPC and under-regulation of affect. BPD+SoD. df = 3.05 . and total TPC experiences for diagnostic study groups. partial eta squared = .08. p < . Correlations between affect dysregulation and TPC for total sample N = 471 Developmental epoch 0-6 years Developmental epoch 7-12 years Developmental epoch 13-18 years Sexual TPC Emotional TPC Physical TPC Over-regulation of affect . the developmental epochs at which TPC occurred in childhood.04 Chapter four 57 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation Note: * p ≤ .62. On a categorical level only the association between over-regulation and total SRIP (r = .000. and emotional TPC severity and early developmental TPC showed a significant overall between group effect: F (6.08 .01 . compared to 70-80% of the BPD and BPD+SoD participants.02 . but not for sexual TPC.09.10* Under-regulation of affect . p <. The BPD+SoD group was significantly more likely than other groups to report TPC and the SoD group was significantly less likely to report TPC (χ2 = 28. ** p ≤ .01) remained its significance but disappeared for developmental epoch 0-6 years and for under-regulation of affect with total SRIP. partial eta squared = .not strong.and total TPC experiences. as well as for developmental epoch 0.76. Figure 1 presents the comparison of mean scores for TPC types.001) and over-regulation with developmental epoch 0-6 years (r = . Wilks’ Lambda = .00 .03 .85. 1326) = 5.11* .

p <.01*** 4. somatoform disorder.0% 58 Note: BPD.4 77 48. partial eta squared = .05 . Over-regulation of affect also differed between the diagnostic sub-groups after controlling for the effect of trauma history.6% 470 100.6% -1.04 .1*** 5.0 33 51.12.79*** 8.4% Traumatic events by primary caretaker 85 71. 464) Emotional TPC Physical TPC Sexual TPC Total TPC experiences Developmental epoch 0-6 Developmental epoch 7-12 Developmental epoch 13-18 Under-regulation of affect Over-regulation of affect 6. residual Frequency SoD % group Std. Residual.03 .01 . Table 4.05 . borderline personality disorder. residual Frequency PC Total % group Std.0% 129 100. Presence of Trauma-by-Primary-Caretaker for Diagnostic Groups No traumatic events by primary caretaker Frequency BPD % group Std.size: F (3.4% 1.2 229 63.6% -1. residual Total % group 34 28.001. residual Frequency BPD+SoD % group Std. Between group differences for TPC experiences.6 31 48.64*** 26. standardized residual values.57** 7. psychiatric comparison group. SoD.81*** 6.001. developmental epochs and affect dysregulation F(3. *** p ≤ .9 100 77.05 .005.6 29 22.1 81 51. A negative value indicates “less frequent than expected” and a positive value indicates “more frequent than expected”.43 7.4% 1.6 171 36.01.14 .7% 2.33*** Partial eta-squared .14. Cells with values less than -2 or greater than 2 are statistically significant and are identified in bold type. PC.3% -1. Std. p =.0% 64 100. Table 3.5% 2.03.30. borderline personality disorder and somatoform disorder.08*** 1.0% Total 119 100. BPD+SoD.5% -2. partial eta squared = . 461) = 24. .04 . although with a smaller effect size: F (3.03 Note: ** p ≤ . 461) = 4.0% 158 100.

developmental epochs.63) OverUnderregulation regulation of affect of affect 77.43) 3.23) 3.64) 3. SD.22) 5.42) 1. BPD+SoD.28 (2. Means and SD for scores for TPC types.47) 1.83) 7. SoD.22 (8.26 (17.84) 6.93 (2.80 (.66 (2.00 (2. standard deviation Table 5 shows the means and SDs of TPC experiences.30) Note: BPD.35 (4.26) 5. Comparison of TPC types.70 (19. under.89 (2. and total TPC experiences for diagnostic study groups Table 5.89) 72.37) 3.TPC across all three childhood developmental epochs Both the BPD+SoD and BPD groups reported more emotional TPC. SoD. with significant more reports for severe physical.89) 3. BPD+SoD.59 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation Chapter four Figure 1. developmental epochs.11 (4.77 (17.19 (7.61) .06 (17.07) .79 (2. somatoform disorder.70 (2.89 (2.76) 1. and psychiatric control groups.39) 1.78) 3.42 (7.40) 1.02) 8.33) Total TPC 7.90) 2.90) 70.45 (2.61) .44 (1.21) 5.64 (4.74) 2. borderline personality disorder. borderline personality disorder and somatoform disorder.21 (3. the BPD+SoD group reported the most complex trauma histories.55) 8.70 (2.18) 9.19) .64 (2. PC.56 (1.89) 1.19 (2.and over-regulation of affect than did the SoD and psychiatric control groups. Overall.67 (. and affect dysregulation Group BPD SoD Mean (SD) BPD+SoD PC Emotional Physical Sexual epoch epoch epoch TPC TPC TPC 0-6 7-12 13-18 5.48) 3. and affect dysregulation for the BPD.05 (.26 (7. developmental epochs.51) 79.01 (2.35 (4.36) 2. psychiatric comparison group.92 (3.61) 4.81) 1.29 (1. .61 (3.40 (2.43 (1.

Although the relationship of childhood sexual abuse to dissociative symptoms has been investigated in a small sample of adults with psychotic disorders (Offen. However. and over-regulation of affect (and not under-regulation) remained significantly related to PTSD severity across developmental epochs.. ranging from approximately 50% of patients with SoD or other psychiatric disorders to more than 75% of patients with comorbid BPD+SoD. 2002) and inhibitory regulation seem to have been overlooked and may be of particular importance in the assessment and treatment of complex TPC-related pathology such as comorbid BPD+SoD or Complex PTSD (Ford. 2002) and affect dysregulation (Ford. Van Dijke. In line with previous calls for the assessment of the nature of affect dysregulation and differentiating between inhibitory and excitatory regulation in BPD and SoD patients (Van Dijke. Almost two-thirds of participants reported having experienced childhood TPC. particularly those with BPD. et al. 2002. These findings are consistent with recent neuroimaging results (Lanius et al. 2010). and differentially associated with under. For a subsample of patients with comorbid PTSD interestingly no significant associations between affect dysregulation and developmental epochs or TPC were found. 2005). 2005). in this study BPD was associated with TPC that occurred in each of the three childhood developmental epochs. 2011) that suggest that there may be an overregulated (dissociative) sub-type of PTSD. This finding is in accordance with previous findings that child abuse and neglect are associated with BPD (Yen et al. although this was not limited to participants diagnosed with SoD but also included those diagnosed with BPD. Thus study findings suggest that childhood trauma by primary caretaker is prevalent among psychiatric patients. 2010.. Waller. Jurist.and over-regulation of affect than the presence of a SoD diagnosis. Gergely... 2010. under-regulation of affect was associated with emotional TPC and TPC occurring in developmental epoch 0-6. & Target. Zanarini et al. Over-regulation of affect was associated with physical TPC.. & Thomas. Van der Hart et al.and over-regulation of affect depending on the type of traumatic exposure. 2003). 2011) and current proposals for DSM V ( ar.DISCUSSION BPD and SoD may be among the numerous final common pathways that occur when affect regulation is compromised as a result of early life interpersonal traumatization and disruption in (or unavailability of) caregiving relationships. Ford. also for PTSD patients difficulty with addressing and analyzing emotions or “mentalising emotions” (Fonagy. this is the first study to our knowledge that examined the potential differential relationship of several forms of trauma by a caretaker (TPC) within distinct epochs of childhood with affect dysregulation in a large sample of adults with well-defined severe psychiatric illnesses. whereas prior studies have emphasized the role of TPC in early childhood as a contributor to BPD and affect dysregulation. particularly among adults with BPD. Consistent with our hypotheses. The presence of a BPD diagnosis was more consistently associated with a history of emotional TPC and with both under. 60 .

Van Dijke et al. particularly under-regulation of affect.. 1992. 2008.. Chapter four 61 Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation Future Directions Study findings are consistent with prior calls for more systematic differentiation between under-regulation and over-regulation of affect (Van Dijke. 2005) is associated with affect dysregulation and somatic dysregulation (as well as dissociation and significant changes in core beliefs). 2008) in which early childhood developmentally adverse interpersonal trauma (Ford. 1996). 1997. in press) in the study of the traumatic antecedents of affect dysregulation (Herman. The finding that emotional TPC was most consistently associated with BPD and with under-regulation of affect is consistent with the findings of Teicher and colleagues (2006) that emotional abuse was a more robust predictor of biological and psychological dysregulation than was physical or sexual abuse. This is consistent with a complex post-traumatic stress disorder (CPTSD) formulation (Ford. Pelcovitz et al. The interrelationships between under-regulation or over-regulation of affect. The finding that the comorbid diagnosis of BPD+SoD -even more so than BPD alonewas particularly associated with the severity of physical TPC and over-regulation of affect . 1997.This suggests that early life attachment-trauma might have adverse effects on affect regulation and interpersonal functioning as a result of cumulative (re)traumatization (Follette & Vijay. especially in poly-victimized children (Finkelhor et al. Van der Kolk et al. This is consistent with prior evidence that BPD is not primarily a disorder related to childhood traumatic victimization (Golier et al. and the range of psychiatric disorders remain to be explored. 2009).. Roth et al. suggest that there may be more extensive sequelae associated with violations of bodily integrity (which may include but does not specifically involve sexual violations) than are accounted for by the BPD diagnosis alone. 2003). 2006. because the differential roles of violations of bodily integrity relative to overregulation of affect and wounding of one’s feelings or lack of appreciation of the self/ identity .. 2007). The findings also suggest that factors other than childhood traumatization by a primary caretaker are likely to account for subsequent affect dysregulation. It would be interesting to assess reported attachment-trauma and over-regulation of affect relative to the revised CPTSD/DESNOS symptom set identified in a recent factor analytic study (Ford.. and warrants attention as a less obvious but potentially pernicious source of affect dysregulation and personality pathology. 2008) as well as (or instead of) due to its neurobiological and psychological effects on early childhood development per se. different types and developmental epochs of exposure to psychological trauma and associated disruptions in attachment. McLean et al. although the present study’s results do not rule out a potential role for childhood traumatization by other adults in the under-regulation of affect characterizing BPD or in the weaker but still evident association between BPD and over-regulation of affect... Emotional abuse can often occur with physical or sexual abuse.

62 CONCLUSION This study assessed the relationship between self-reported childhood traumatization caused by a primary caretaker for specific childhood developmental epochs and affect dysregulation in BPD. Mulholland. Infrequent reports of sexual abuse may also be related to the fact that participants were diagnosed with comorbid PTSD (not primarily diagnosed with PTSD). there might have been more under-reporting than overreporting of these events due to the emotions that were evoked and the difficulty in handling these emotions and cognitions. 2008). This may perhaps constrain the generalisability of the findings for PTSD-only populations. McCusker. schizophrenic patients were found to reliably report sexual trauma history over a one-year period (Klewchuk. Overall. For instance. while showing evidence of “enhanced cognitive schemata” that may bias recall. the relationships were relatively weak. Limitations This study explored the potential role of childhood traumatization caused by a primary caretaker occurring during discrete developmental epochs in the development of affect dysregulation. 1992). When diagnostic groups were examined separately. Psychopathology does not necessarily equate with inaccuracy of trauma memory reporting. When considering our sample population as a whole. & Shannon. the clinical observations is that participants who did report early TPC experiences found it difficult to do so. and psychiatric control patients. efforts were made (with patient consent) to confirm the reported traumatic events with close relatives following procedures described in the “Clinical Assessment of Trauma-Related Self and Affect dysregulation” (Van Dijke.relative to under-regulation of affect might be distinguished for patients with the CPTSD/ DESNOS symptom set. suggesting that heterogeneity within the samples may have diluted the findings. while over-regulation of affect was related to physical TPC. 2007). BPD was associated with emotional TPC across all developmental epochs of . However. SoD. Retrospectively self-reported types and times of exposure to psychological trauma may be inaccurate under these circumstances due to the potential influence of current PTSD symptom severity on trauma history reporting (Sutherland & Bryant. therefore. BPD+SoD. 2008)or may be hampered due to psychological defense against remembering early childhood TPC and holding on to a “belief in a just world” (Herman. Data were obtained from a psychiatric population consisting of clinically admitted psychiatric patients with persistent psychopathology. Nevertheless. under-regulation of affect was significantly related to emotional TPC and the 0-6 year old developmental epoch. The finding that sexual abuse was infrequently reported also may have reduced the study’s ability to detect relationships with this type of TPC.

childhood and emotional TPC was associated with under-regulation of affect. The BPD+SoD group was the most likely to report early TPC and both forms of affect dysregulation. Thus, our findings indicate the importance of examining the role of emotional abuse in severe psychiatric disorders, and the combination of affect under-regulation and over-regulation associated with early TPC especially in more complex disorders such as the combination of BPD and SoD.
Chapter four

63
Childhood Traumatization-by-Primary-Caretaker and Affect Dysregulation

Chapter five
Complex Posttraumatic Stress Disorder in Patients with Borderline Personality Disorder and Somatoform Disorders

Van Dijke, A., Ford, J.D., Van der Hart, O., Van Son, M.J.M., Van der Heijden, P.G.M., & Bühring, M. (2011). Complex posttraumatic stress disorder in patients with borderline personality disorder and somatoform disorders, Psychological Trauma: Theory, Research, Practice, and Policy

ABSTRACT Introduction
Prior studies have reported an elevated risk of childhood trauma exposure or Complex PTSD symptoms. also known as Disorders of Extreme Stress Not Otherwise Specified (DESNOS). in persons diagnosed with borderline personality disorder (BPD) and somatoform disorders (SoD). However, Complex PTSD/ DESNOS, BPD and SoD were never assessed in unison.

66

Methods
Complex PTSD/ DESNOS symptoms and the full syndrome were assessed and compared in a sample (N = 472) of adult psychiatric patients with confirmed diagnoses of Borderline Personality Disorder (BPD), Somatoform Disorders (SoD), comorbid BPD+SoD, or Affective or Anxiety Disorders (Psychiatric Controls, PC).

Results
BPD+SoD patients had the most extensive childhood trauma histories and were most likely (38%) to meet Complex PTSD/ DESNOS criteria, followed by BPD (26%), PC (17%), and SoD (10%), The BPD+SoD and BPD-only groups reported significantly higher levels of complex PTSD/ DESNOS symptoms than the SoD or PC groups, and did not differ from each other except for greater severity of complex PTSD/ DESNOS somatic symptoms by the BPD+SoD group.

Conclusion
Complex PTSD/ DESNOS warrants further investigation with psychiatrically impaired adults as a potential independent syndrome or as a marker identifying a sub-group of affectively or both affectively and somatically dysregulated patients diagnosed with BPD who have childhood trauma histories.

. 2005). & Turner. 2007. including depression. 2004. 1994. Kaltman. 2009). Schnurr. the DSM IV lists the DESNOS symptoms not as a distinct diagnosis but under the rubric of “associated and descriptive features” of PTSD (APA. Ford.. severity. Koenen. Ford. & Cloitre. Nishith. a consideration for treatment planning (Cook. Courtois. Alessi. Alexander. Complex PTSD was not codified as a diagnosis in the fourth edition of the American Psychological Association’s Diagnostic and Statistical Manual (APA. & Spinazzola. 2007. Aspelmeier. Van der Kolk. relegating other posttraumatic sequelae to “associated features” or “comorbidities” may interfere with a comprehensive and effective treatment approach (Courtois & Ford. & Frueh. phobias. 2003). However. focusing on PTSD symptoms and.In adulthood. & Green. 2008. & Friedman. & Foa. Van der Kolk. & Han. 2005). & Nijenhuis. 2009) and in adulthood (Briere. Cloitre.INTRODUCTION Sequelae of early life “neurodevelopmental injury” (Kaffman. & Alexander. Hawke. Although the DSM IV Subcommittee on PTSD favored the creation of a separate diagnosis to capture the psychiatric symptomatology related to chronic exposure to interpersonal trauma (Van der Kolk et al. 2010. 2002. & Green. & Hawke. Elliott. Aspelmeier. 2009. refers readers to the “rich empirical Chapter five 67 Complex Posttraumatic Stress Disorder . Richmond. anxiety. Cohen & Hien. Steele. and shattered or altered basic beliefs. Chapman et al. 2009.. 2004. 1992) or Disorders of Extreme Stress Not Otherwise Specified (DESNOS. Van der Kolk et al. 2003) of relevance to clinical practice and research with survivors of psychological trauma. & Kantor. Resick. and a treatment outcome domain (Brand. 2006. at best. and range of clinically-significant symptoms in childhood and adolescence (Cloitre et al. Elliott. Whereas the PTSD diagnosis is likely to fit some of the psychiatric problems of many psychiatrically impaired traumatized individuals. Courtois. Holt. 1998). & Anda. Pierce. these complex traumatic stress reactions may constitute a syndrome of Complex PTSD (Herman. Hart. 2009) have been described as epidemic and under-studied. Cloitre. Finkelhor. 2000). Ledgerwood. Ford & Kidd. dissociative with and somatoform disorders. 2005). Stockton. somatization. McNary. the first edition of the Treatment Guidelines of the International Society for Traumatic Stress Studies (Foa. 2000). p. Classen. Elhai. 2009. Ford. & Petry. Keane. 2009. Complex PTSD increasingly has been recognized as a potential prognostic factor (Ford.. For example. & Zaveri. Edwards. Ormrod. & Richmond. dissociation. Ford. 2009. Cohen. Felitti. Ford. M. 2005. Sunday. Pierce. Roth. Increasing complexity of psychological trauma exposure has been shown to be strongly associated with corresponding increases in the extent. Connor. Holden. Connor. Pelcovitz. while recognizing that over 80% of patients PTSD suffer from comorbid conditions. 2005) that includes problems with affect dysregulation. Adults who were exposed to chronic interpersonal trauma often demonstrate complex psychological disturbances that are not fully captured by the posttraumatic stress disorder (PTSD) diagnosis (Ford. Kaltman. & Griffin. 2006.. Finkelhor. 2007. 2009. 425).

.. Where possible.g. with small samples of entirely (McLean & Gallop.. Zanarini. e. applicable to these “co-morbid” conditions in patients with PTSD. However. Rotterdam (N = 355) who participated in the multicentre project “Clinical Assessment of Trauma-Related Self and Affect Dysregulation” (Van Dijke. Studies have reported an elevated risk of childhood trauma exposure or Complex PTSD symptoms in persons diagnosed with borderline personality disorder (BPD. 2009). & Frankenburg.. only three of these studies assessed the full Complex PTSD criterion set. 2003) or predominantly (Spitzer et al. severe conversion and pain disorder) diagnoses were confirmed by trained clinicians using the BPDSI and the CIDI (see below).g. The present study therefore was designed to systematically assess Complex PTSD in a large adult psychiatric sample with four distinct sub-groups: BPD. Ford. 2005.. 2003.e. comorbid BPD+SoD. and altered life schema problems represented by Complex PTSD (Busuttil. 2002) and somatoform disorders (SoD. 1994. Diagnoses of BPD and SoD were made during intake according to the DSM-IV criteria. McLean & Gallop. Delta Psychiatric Center.. dissociative. No significant effects were found for sex. Saxe et al. . and other psychiatric disorders. Yonge. separately and comorbidly. 1999) psychiatric patients. general practice and former hospital records were obtained (with patient’s consent) and studied. 1999. with early childhood trauma exposure and complex PTSD symptom severity and syndromal prevalence. Schrag. Altrecht Utrecht (N = 117) and De Waard. somatization disorder. e. SoD. 2009). and level of education on the dependent variables. Eikenboom Center for Psychosomatic Medicine. In the recently updated ISTSS treatment guidelines for PTSD only two studies are cited that involve complex trauma populations and there was no mention of techniques to deal with the severe affect and somatic dysregulation. there is no evidence that other treatment manuals are.. BPD and SoD (i. 2008). Brown. in fact. undifferentiated somatoform disorder. 2009) female or entirely male (Ford. Yen et al. & Trimble. Table 1 presents the demographic characteristics of the four study groups and the total sample. None of these studies directly compared patients with BPD to those with SoD. (Spitzer et al. However. In fact. no study has systematically examined the association of BPD and SoD. 2002.literature of these co-morbid conditions” (p. 68 METHODS Participants and Procedure Participants were 472 consecutive admissions to two adult inpatient psychiatric treatment centers. 375) for treatment guidance. This study was approved by the local ethics committee and included written consent from all participants.

Van Dijke & Van der Hart.9 29. dissociation. WHO. middle level secondary education.9) 28. 2002) was used to assess Complex PTSD. borderline personality disorder and somatoform disorder.6 % 45. psychiatric comparison group.8) 30. Dutch version.91). and dissociation and paranoia) corresponding to the symptom clusters of BPD. affect dysregulation. M.1 24.e. self-image.1) 40. Arntz. BPD+SoD.3 (10. 2003) is a semi-structured interview that contains nine sections (abandonment.. N. Current rather than lifetime Complex PTSD was assessed in order to reduce reliance on retrospective reports. SoD diagnoses were confirmed by independent review by a psychiatrist with somatic experience. 2002).7 PC 64 28 36 36. Arntz.8 (9. CIDI diagnoses have acceptable reliability and validity (Andrews & Peters. Educ. Weaver & Clum.7 Total Sample 472 145 327 34. Ford & Kidd. 2003)..4 BPD+SoD 129 30 99 33.e.1 34.Table 1 Demographic Characteristics of the Study Groups and the Total Sample BPD N= Male Female Age M (SD) Social N T S L M H 120 40 80 29. relationships. 1993.3 15. Partial (Ford & Smith. The BPDSI has been shown to have good validity and reliability (Arntz et al. emptiness.5 Chapter five Educ Note: BPD. H. Social. separated by death or divorce. PC. Self-report of potentially traumatic events was assessed with the Traumatic Experiences Checklist (TEC. highest level of education attained.1 % 37.. affect. L. no primary partner.3 % 41.9 31. self.5 13. a retrospective .. borderline personality disorder. somatization) and one of the three altered fundamental beliefs sub-scales (i.1) 37.6 23. 1998) is a standardized interview for assessing mental disorders according to the definitions and diagnostic criteria of DSM-IV and ICD-10. 1998).5) 45. The Borderline Personality Disorder Severity Index (BPDSI. Ter Smitten et al.. World Health Organization.4% 41.1% 56. impulsivity.2 22. et al.8 8.9 (8.3 % 47. 1998. living together. 2008) as well as full Complex PTSD was included.3 24. primary relationship status. Dutch version IV. The Dutch self-report version of the Structured Interview for Disorders of Extreme Stress Not Otherwise Specified (SIDES-rev. October 2003).4% 46. requiring the presence of at least two of the primary Complex PTSD features criteria (i.2 35. Dutch version.6 (9. Van der Hart. Nijenhuis.7 (10. a specialist in internal medicine. T. 1997.8 % 60.4 27. The SIDES-rev-NL total score showed evidence of internal consistency in this sample (Cronbach’s α = 0. somatoform disorder. S. primary and low-level secondary education. or a general practitioner with psychiatric experience.9% 50. 69 Complex Posttraumatic Stress Disorder Measures The Composite International Diagnostic Interview (CIDI. relationships. a cut-off score of 20 was used to diagnose BPD (personal communication. systems of meaning). SoD.0 12. high-level secondary education. & Kruger.2 % 35. parasuicide.3 12. anger.8 40 SoD 159 47 112 38.

logistic regression analysis was done with Complex PTSD classification as the dependent categorical variable. The TEC has been shown to have acceptable reliability and validity among psychiatric outpatients (Nijenhuis et al. . 2002). a MANCOVA was conducted including PTSD severity as the covariate. controlling for the effects of trauma history (i. & Rivero. 1994). in order to determine if the relationship of the psychiatric disorders with Complex PTSD can be fully or partially accounted for by severity or epoch of trauma history. and Hyperarousal can be calculated by adding the scores on the relevant items. Avoidance. (b) 7-12 years. Scores for the subscales of Intrusion. Finally. Composite scores were calculated for the number of types of (a) emotional.. Bramsen. Group means for the composite traumatizing event and developmental epoch scores were compared using multivariate analysis of variance (MANOVAs). & Van der Ploeg. This sub-sample did not differ significantly from the total sample on age. A total score is calculated by adding all scores. Schreuder. Cross tabulations with Chi-square tests were used to determine whether Complex PTSD was differentially likely across the diagnostic groups. Bramsen. In order to determine if the differences attributed to Complex PTSD were distinct from those due to PTSD. All patients classified as Complex PTSD (full or partial) were compared to those not meeting criteria for Complex PTSD on mean scores for each type and epoch of traumatic exposure with a MANOVA.e. with 100 % agreement. Further. and diagnostic group representation. PTSD was assessed with a sub-sample of patients from the Delta PC study site (N=133) using Self-Rating Inventory for Posttraumatic Stress Disorder (SIRP. The sequence of the items does not follow DSM-IV but has been randomized. and the four diagnostic groups were compared on continuous SIDES subscale and total scores with a multivariate analysis of variance (MANOVA). Klaarenbeek.questionnaire. and diagnostic groups (using psychiatric comparison participants as the reference category) as the independent variable. (c) 13-18 years. 2000). TEQ scores). (b) physical. gender. a DSM – IV diagnosis can be calculated by using an algorithm (Hovens. and for the number of traumatic experiences in each of three childhood developmental epochs: (a) 0-6 years... indicating intensities. 70 Statistical Analyses All statistical analyses were performed using SPSS. and (c) sexual traumatic experiences reported. This inventory has 22 items reflecting the 17 symptoms from DSM-IV. Delta Psychiatric Center site participants had reports of trauma confirmed by close relatives. All items are scored on a 4-point rating scale with anchors of 1: not at all and 4: very much. version 16 (SPSS Chicago). Hovens.

The BPD and BPD+SoD groups more frequently than the SoD or PC groups reported each type of traumatizing stressor and exposure in each childhood epoch: F (15. Wilks’ Lambda = . psychiatric control group.001).8% . Wilks’ Lambda = . SoD. borderline personality disorder and somatoform disorder.3% Complex PTSD 31 25. Residual. with large between group effect sizes for all . Cramer’s V = .0% 129 100.3 49 38. 466)= 5.05.87. A negative value indicates “less frequent than expected” and a positive value indicates “more frequent than expected”.RESULTS Most patients (89%) reported experiencing at least one potential traumatizing event. p < .001. Wilks’ Lambda = .0% 3.46. The SoD group was significantly less likely than the BPD+SoD group to meet Complex PTSD criteria (χ2 = 33. Table 2 reports the likelihood of meeting current full/partial Complex PTSD criteria for each of the diagnosis groups. borderline personality disorder.8% . partial eta squared = .8 80 62. p < . BPD+SoD. residual Frequency SoD % group Std.2% -. Most SoD and psychiatric comparison group members (83 – 90%) did not meet criteria for Complex PTSD.2% -. p< . somatoform disorder. residual Frequency PC Total % group Std.000. Using the SIDES-rev-NL total and sub-scale scores as dependent variables. Complex PTSD-positive participants more frequently than those who did not meet criteria for Complex PTSD reported all types of traumatizing stressors and exposure in all childhood epochs except for developmental epoch 7-12 years: F (5.0% -2. partial eta squared = .001.9% 1.5 365 77. p <. Presence of Complex PTSD in Each Diagnostic Group No Complex PTSD Frequency BPD % group Std.0% Total 120 100.59.32. standard residual values. Cells with values less than -2 or greater than 2 are statistically significant and are identified in bold type. an overall between-groups difference was found in a MANOVA (F (21.11.27. residual Frequency BPD+SoD % group Std.7 16 10.1% -3.4 143 89.16). residual Total % group 89 74.95. Table 2.0% 159 100.001. 1290) = 13. whereas more than one quarter of the BPD and almost 40% of the BPD+SoD participants met Complex PTSD criteria.0 51 82. df = 3.0% 64 100. p < . PC.9 107 22. partial eta squared = .05.7 11 17. Std.0% Chapter five 71 Complex Posttraumatic Stress Disorder Note: BPD.7% 472 100. 1281)= 4.36.

44) 7.25 . standard deviation.13.27 (3.29 (4.84 (2. Wilks’ Lambda = . The multivariate effect for PTSD was statistically significant (F (7.77) 2.40*** Partial eta-squared .07).48*** 13. partial eta squared = .70) Mean 51.12*** 51.46) 3. psychiatric comparison group. borderline personality disorder. overall group differences were no longer significant and the effect size was reduced (F (21.18 .22. Inclusion of the ten independent variables improved the fit of the model significantly . In a logistic regression analysis.001. 455) Total SIDES-rev-NL score Dysregulation of affect and impulses Dissociation Alterations in self-perception Distorted relations with others Alterations in one’s system of meaning Total somatic complaints 59.001. but not with BPD alone nor with or any trauma history variable (Table 5). Complex PTSD was associated positively with BPD+SoD and inversely with SoD.97 (2. p = .74) 2.64 (2.43). borderline personality disorder and somatoform disorder.92) 31.SIDES-rev-NL sub-scales and the total SIDES-rev-NL score (Table 3). 122) = 13. 350) = 1.80.88 (2. partial eta squared = .13 (4.29) Distorted Alterations in Total relations one’s system somatic with others of meaning complaints 10.41) PC N = 58 Mean 56. Wilks’ Lambda = .83 (2.04) 12.73 (7. Table 4.49) BPD N = 118 SoD N = 156 BPD+SoD Mean 69.02. SD.43) 10. PC. *** p £ .49) 30.06) 23.96) 10.76 N = 127 SD (13.11 72 Note:.23 .41*** 44. partial eta squared = .77) 8.40 (3.77) 7.37.31 (3.66 (2. Between Group Differences for Complex PTSD Features F(3.57 (3.19) 12.23 .89) 3. p < .60 (2. SoD.55 (1.48 SD (12.72 (2.00) 4.52-3.86) 25. BPD+SoD.89 (1.82 (2.37) 9. When severity of PTSD symptoms was included in the analysis (MANCOVA) as a covariate.67) 8.20) 8.28 .08 .53*** 32. for the smaller sample with whom PTSD was assessed (N= 133).46) 6.57.77. Comparison of Diagnostic Groups on SIDES-rev-NL Scores Group Total Dysregulation Alterations SIDES of affect and Dissociation in selfScore impulses perception Mean 69.23 (3.68*** 18.49 (1. somatoform disorder.73 (7.34 SD (11. p = . df = 3.78) Note: BPD. Table 3.46) 5.35 ( .18 SD (16.18*** 44. However. the univariate effects for diagnostic group remained statistically significant for the total SIDES-rev-NL score and the affect dysregulation and dissociation sub-scores (F= 3.08). The BPD and especially BPD+SoD groups reported higher Complex PTSD scores than the SoD and psychiatric control groups (Table 4).92) 9.24 (6.26 (6.16) 6.

df = 8. SoD alone (Spitzer et al.. the somatization component of Complex PTSD appeared to be related to SoD. Complex PTSD was prevalent (i. 2002) were as strongly associated with risk of Complex PTSD as the combination of BPD+SoD.39* 2.73 1.05 .37. This is consistent with prior studies showing a relationship of BPD and Complex PTSD (Ford. 2009).96 .44 . 2003). PC. df = 9.0 % C.04 . For Odds Ratio Chapter five lower PC (reference group) BPD SoD BPD+SoD Total emotional trauma Total physical trauma Total sexual trauma Total developmental epoch 0-6 year Total developmental epoch 7-12 Total developmental epoch 13-18 1. 2003).17 1.82 1. somatoform disorder. DISCUSSION Exposure to potentially traumatizing events was prevalent in a sample of psychiatric inpatients. psychiatric comparison group. p <. present in 23% of the sample). 1999.I.05. 2009).. 2005).44. borderline personality disorder and somatoform disorder.63 .95 . Van der Kolk.63 Upper 3.89 .e. Logistic Regression Analyses for Variables Associated with Complex PTSD Classification N=472 Odds Ratio 95. particularly in the BPD+SoD subgroup.60)...02 1. Table 5.03 1. specific tests of distinct psychiatric disorders other than BPD and SoD are warranted before concluding that the latter diagnoses are the principal psychiatric disorders associated with Complex PTSD features. 1999. nor psychiatric morbidity (Yen et al.56 . borderline personality disorder. These results are in line with prior findings that the long-term sequelae of childhood trauma do not seem to be encompassed by any single DSM-IV-TR disorder (Ford. while the remaining Complex PTSD features were more related to BPD than SoD. In contrast to prior observational study findings.14 .96 1. .18 1. particularly among those diagnosed with BPD alone or comorbid BPD+SoD.29* 1. and extends those findings by showing that the relationship may be most likely for a sub-group of BPD patients who also meet criteria for SoD (Spitzer et al.43 73 Complex Posttraumatic Stress Disorder Note: * p < 0.24 . BPD+SoD. General psychiatric impairment was associated with levels of severity of Complex PTSD and each of its features that were comparable to those of SoD and lower than those of the BPD sub-groups. SoD. Van der Kolk et al..14 . 2005. neither BPD alone (McLean & Gallop. p = 0.09 1.77 .84 4.05 2. McLean & Gallop. BPD.59 1. Expectably.(χ2 = 53.001). The Hosmer-Lemeshow test revealed that for all dependent variables the model fits the data well (χ2 = 6. for whom Complex PTSD was significantly more likely than in the SoD sub-group. However.

Complex PTSD usually (but not always; e.g., Ford, 1999) is observed to occur comorbidly with (rather than independently of PTSD).Whether Complex PTSD represents a complex variant or sub-type or comorbidity marker for PTSD (Briere & Jordan, 2009; Briere et al., 2008; Resick & Miller, 2009), or distinct posttraumatic syndrome, remains uncertain (Van der Kolk et al., 2005). In the present study, PTSD symptoms were found to account for most of the multivariate association of BPD and SoD with Complex PTSD, thus supporting the view of Complex PTSD as a complex variant of PTSD. However, the associations between BPD and SoD diagnostic groups and the severity of Complex PTSD and its affect dysregulation and dissociation features persisted after controlling for PTSD severity. Thus, certain features of Complex PTSD that are conceptually related to PTSD (i.e., arousal-related somatic dysregulation; altered personal schemas) may be largely accounted for by PTSD, but Complex PTSD features that are more clinically and conceptually distinct from PTSD (i.e., affect dysregulation, dissociation) appear to be empirically distinct from PTSD in this sample of adults with severe psychopathology. The prominent role of dissociation in Complex PTSD and BPD have led to the proposal that complex PTSD may be a dissociative disorder (Van der Hart, Nijenhuis, & Steele, 2005). Affect dysregulation also has been hypothesized to serve as the core feature of Complex PTSD (Ford, 2005). Further research thus is needed to clarify the relationship of PTSD, affect dysregulation, and dissociation in Complex PTSD in psychiatric and other samples in which trauma exposure is prevalent. The full Complex PTSD syndrome is rare (i.e., <1% prevalence) in non-clinical populations, but Complex PTSD symptoms are common and are associated with childhood traumatic experiences (Ford, Kaltman, Stockton, & Green, 2006; (Scoboria, Ford, Lin, & Frisman, 2008). The present study’s results indicate that a larger sub-group of psychiatric patients may meet criteria for the Complex PTSD syndrome (i.e., 10-38%), comparable to findings with a trauma-exposed substance abuse treatment sample (Ford & Smith, 2008). Although comorbid BPD+SoD was particularly related to risk of Complex PTSD, patients who qualified for Complex PTSD nevertheless were only a minority of the BPD+SoD subgroup. Further, meaningful sub-groups of patients with BPD (26%), SoD (10%), or other psychiatric disorders (17%) meet Complex PTSD criteria. Thus, it does not appear that Complex PTSD is simply synonymous with comorbid BPD+SoD nor with BPD. It may serve as a useful marker to identify psychiatrically impaired patients with particularly severe affect dysregulation, dissociation, somatization, and alienation from self and others, as well as providing specific continuous and categorical variables to track clinical outcomes.

74

Future Directions
In order to establish Complex PTSD as a syndrome with sufficient clinical utility to warrant a unique diagnosis, however, numerous additional tests of its usefulness to practicing clinicians and as a guide to incrementally enhanced treatment effectiveness are needed (First et al., 2004). For example, research might test whether treatment designed specifically to

address Complex PTSD features (e.g., Steele & Van der Hart, 2009) particularly enhances outcomes for BPD+SoD patients who meet criteria for Complex PTSD (versus for all BPD+SoD patients). Another clinical utility issue warranting investigation is whether the association of Complex PTSD with BPD+SoD can be accounted for by Axis I or II comorbidity, given evidence of substantial comorbidity in both SoD (Lieb, Meinlschmidt, & Arava, 2007) and BPD (Yen et al., 2002; Zanarini et al., 2002).
Chapter five

Limitations
Limitations of the study include the use of a self-report version of the SIDES, rather than the interviewer version validated by Ford and Kidd (1998), reliance on clinician rather than research ratings of the diagnostic variables, use of retrospective self-report to assess trauma history, and inclusion of only two specific psychiatric diagnoses and the general class of severe affective/anxiety disorders as a focus. However, the study’s strengths include a large sample with precisely documented index diagnoses, detailed (and reliable, when collateral confirmation was possible) assessment of childhood trauma history, and use of the SIDES to assess all Complex PTSD features. Future studies are needed to replicate these findings with alternative methodologies and samples with a variety of specific diagnoses that may be related to traumatic stress and that involve affective and somatic dysregulation (e.g., major depression) in order to determine both the specificity and generalizability of the present study’s preliminary findings of a relationship between severe psychopathology (specifically BPD and BPD+SoD) and Complex PTSD.

75
Complex Posttraumatic Stress Disorder

CONCLUSION
Exposure to potentially traumatizing events was prevalent among psychiatric patients, particularly among patients diagnosed with BPD alone or comorbid BPD+SoD. Also, the present study’s results indicate that a larger sub-group of psychiatric patients may meet criteria for the Complex PTSD/ DESNOS syndrome than was previously accounted for (i.e., 10-38%), particularly in the BPD+SoD sub-group. By including BPD, SoD, comorbid BPD+SoS and other psychiatric disorders in this study, Complex PTSD/ DESNOS could successfully be distuinguished from BPD.

I. A. Emotion regulation: Conceptual and clinical issues (pp. New York: Springer. . (2008). Denollet (Eds. Nyklicek. Vingerhoets. In A. The clinical assessment and treatment of trauma-related self-and affect dysregulation.and affect dysregulation Van Dijke. & J. 150-169).Chapter six The clinical assessment and treatment of trauma-related self.).

traumatized people are frequently misdiagnosed and mistreated in the mental health system. Next to having outlined the theoretical background and the rationale of our assessment procedures and treatment program. an integrative psychotherapy program encompassing a multidisciplinary therapy program in clinic. They may become engaged in ongoing. Therapists of different disciplines collaborate in inpatient therapy sessions in order to assess signs and symptoms associated with affect dysregulation. destructive interactions.ABSTRACT In this chapter the concept of affect dysregulation was redefined. 78 . The approach is characterized by its multidisciplinary background. . day-clinic and outpatient setting was outlined... in which the medical…system replicates the behavior of the abusive family.Herman (1992a. Because of the number and complexity of their symptoms. p. The assessment program has been proven to be successful and helpful in indicating patients for treatment and in assessing treatment progress and treatment effect. their treatment is often fragmented and incomplete. The relevance of clinical assessment and treatment of Self dysregulation and affect dysregulation in a psychiatric hospital was discussed. they are vulnerable to become re-victimized by caregivers.regulation and over-regulation of affect and treatment possibilities. 123) . Finally. more specific under. some typical cases were presented. Because of their characteristic difficulties with close relationships.

The aim of this chapter is to discuss the nature and significance of affect-dysregulation2 in complex and chronic psychiatric patients. Van der Kolk (1996) concluded that one-to-one notions about causal relationships between reported trauma features and the presence of psychiatric disorders in adulthood are an oversimplification of the problem. 1996). Especially in complex psychopathology patients. & Weisaeth.and affect dysregulation The Theoretical and Clinical Relevance of Affect Dysregulation According to Zajonc (1984).g. McFarlane. 2 Despite similarities and differences “affect” and “emotion” are used as synonyms . Affects are facts in the way. the initial processing of stimuli implies the appraisal of the affective tone of a stimulus as ’positive or negative’. clinic for inpatient psychotherapy treatment and Altrecht “Eikenboom”. cognitive. & Pearlstein. elaborations on theoretical perspectives. e. and characterological (Allen. Herman. (psycho)somatic disorders. It may have a strong negative impact on all levels of functioning: emotional. Weekends are spent in their home environments to enhance and maintain (family) relations. and implementations of research findings in Mental Health Hospital Delta Psychiatric Centre “De Waard”.INTRODUCTION Exposure to extreme stressors affects people in many ways. Moreover. Despite a vast amount of literature on the aftermath of trauma. 1992b. In addition. somatic. behavioral. anxiety disorders. The presented assessment and treatment protocol is not intended to be a “gold standard” but should rather be considered as “work in progress”. an experimental assessment and treatment protocol for Self. Schore. centre for psychosomatic medicine. standard psychiatric classification and assessment procedures seem to be inadequate and treatment-as-usual or diagnosis-specific-treatment protocols seem to be ineffective.and affect dysregulation will be described for patients suffering from a combination of trauma related psychiatric disorders (mood disorders. Van der Kolk. This implies that affects are most important signals because they carry information about one’s own reactions to life experiences. Zlotnick. somatoform disorders and personality disorders) and PTSD associated symptoms. 1997). 2001a). the long term sequelae of attachment trauma and the complexity of adaptation to attachment trauma are still to be elaborated on. Affect dysregulation is considered a characteristic feature in complex trauma related psychopathology as defined in “PTSD associated symptoms” also known as complex PTSD or DESNOS (Disorders of Extreme Stress Not Otherwise Specified. or ’safe or threatening’. that they give and content information about one’s own reaction in relation to the outer world and one’s inner world (Schore. Chapter six 79 The clinical assessment and treatment of trauma-related self. Patients come in on Sunday nights and leave on Friday afternoons. 2001. 2002. The assessment protocol and treatment protocol encompass lessons learned from working with traumatized patients suffering from affect dysregulation.

& Hurley. 1973. Gergely.In this way. & Pereg.. despite a vast amount of research. without being overwhelmed with emotions or being numbed. behavioral. . The importance of affect for patients’ therapeutic changes had moved to the background.. Experiencing emotions. Schore. emotional. 1999). 2001a. Shaver. (2003) come to the conclusion that since the publication of Bowlby’s trilogy. 1980. The role of experiencing emotions while maintaining a sense of agency is to give meaning (Fonagy. It is of fully experiencing emotions that one wonders why situations give rise to emotions and that one re-evaluates his situation. 80 Development and Affect Our cognitive. 2002). Wolf. Wendelken. Kaplan. and social development occurs in an interpersonal context (Bowlby. Mikulincer. it has been established that attachment theory has become one of the most important conceptual frameworks for understanding the development of the Self. most therapies and therapy-effect studies have been focused on cognitions and behavior/ avoidance. 2004). ˇ Temoshok. 1982/ 1969. 2005. assessment. 2003). According to McCullough. behaviors and interactions (and not just through logic without reference to non. Nyklícek. maintaining proximity to significant others and maintaining intimate relations. influences present and future behavior. It is this emotion driven re-evaluation of cognitions. The benefits of expressing emotions for our mental and somatic well-being have been investigated in various ways and in various populations (e. 2002). Nevertheless. Working with strictly cognitivebehavioral techniques will not suffice in cases of complex trauma related psychopathology. in recent decades.. (2003). Given the importance of affect in human functioning. Siegel. Kuhn. and therapy (McCullough. The expression of emotions is important in the interaction with (significant) others and for establishing and maintaining (emotional) contact or relationships with them. et al. one would expect affect to have been at the center of attention in therapy development and therapy-effect studies. To experience emotions while maintaining a sense of agency. they give meaning to one’s experiences (McCullough.g. & Target. 2003). Recently affect seems to receive more appropriate attention due to new developments in theory. affects are fundamental forces in the development and changes of the Self. et al. Attachment and Loss (Bowlby. Jurist.or pre-verbal information). Shaver. Given the close interconnections with cognition. the precise significance of the (non) expression of emotions for psychiatric patients remains unclear. and the process of affect regulation and Self regulation. one needs to be able to regulate affect in different situations (Fonagy et al. & Vingerhoets. et al. Andrews. 2003). and Mikulincer. However. 1982/ 1969. Despite the increasing interest in affect the importance of fully experiencing emotions in more complex psychopathology psychiatric patients remains unclear. 1973. 1980). profound and early affective experiences need to be taken into account when indicating psychotherapy. Gillath. Bunge. which results in changes in the therapeutic process (McCullough.

Siegel. Mentalization is not just a cognitive concept. Bradley. 2002. Mitropoulou.However. if one failed to develop a secure attachment with caregivers? What. 2000. cognition. if human connections were poor and the development of emotional information processing was disturbed? What. what if something went wrong in one’s early social emotional development? What. This early process of interaction is well-known as attachment and it encompasses the development of social and emotional functioning. Serby. For attachment theorists and psychodynamic theorists. 1999). The ability to fully experience emotions implies adequate affect regulation. the main significant Other is normally one’s caregiver. Harvey. soma. during the first years of life. Schopick. Reflective Function and Mentalization are used as synonyms . For some theorists. but a concept of the reflective function which encompasses cognitions. Self regulation encompasses regulation of affect. 2004. Attachment stimulates the brain and thereby seems to improve the quality of the functions of the brain (Bateman & Fonagy.g. Schmeidler.and affect dysregulation Nature of Affect Dysregulation and the Emotional Reflective Function3 The concept of affect dysregulation has never been well defined and little research has focused on the nature of affect regulation and dysregulation (e. behavior and interaction (Van der Kolk. It requires the capacity to envision mental 3 Emotional Reflective Function is also called “Affective Mentalization”. and Siever. affects and behavior as in affective reciprocity. the object of regulation is more complex: the regulation of affects is strongly linked to the regulation of the Self and the capacity to mentalize (Fonagy et al. if there was not a secure holding environment available? What. psychophysiological homeostasis and hormone balance are established and attachment may be a main stimulating factor. 2002). 2002). Particularly the process of interaction with the caregiver is critical for the healthy development of emotion recognition and expression of emotions. 1996). 2001b. if patients suffer from affect dysregulation? How do we go from there? Chapter six 81 The clinical assessment and treatment of trauma-related self. Silverman. These early developmental processes of the brain underline the importance of attachment and attuned emotional relationships. Goodman. In humans. Moreover. Gross 1998. Zittel Conklin.. But. 1999). Koenigsberg. & Westen. New. Positive early human interactions appear to be crucial for the development of neural connections and neural networks necessary for adequate emotional information processing. In order to learn and develop strategies to express and experience emotions adequately one needs to interact from the beginning in an attuned way with significant Others. it has been established that there is a relation between early adverse experiences and the development of affect dysregulation or cognitive-emotional dysfunctioning and that affect dysregulation is involved in the etiology of psychiatric pathology (Bradley. Schore. affect regulation denotes a process wherein the object of regulation is the affect itself. 2006.

on the one hand. At other times she got so mad over small issues that she was not able to do what she planned to do. She was not able to sooth herself and instead she had to get drunk and to vomit severely in order to deal with her emotions. and (4) impulse control problems such as eating problems (lost 40 pounds of overweight in 2 years). .g. She had engaged in several psychotherapies that seemed to work out for her. 1999). the benefits seemed to vanish. aged 36 years. Sometimes she acted really dangerously and hoped she would get hurt or killed while doing it. (3) enmeshed and bad relationships over the years e. When in such a state.states in Self and Others. They make a distinction between under-regulation of affect. due to lack of the specific orienting information associated with each emotion. In the present contribution affect dysregulation encompasses: (1) The incapacity to regulate and modulate affective experience. was admitted to a Mental Hospital with various complaints: (1) being off and on depressed for several years. she had the strong urge to hurt someone and it took almost everything in her not to give in to that impulse. and over. but rather to yell at someone close instead. In daily life situations she easily became very emotional over small things.. (2) The incapacity to experience all aspects of affect. 82 Vignet: Diana. Paivio & Laurent (2001) describe two distinct manifestations of affect dysregulation that are of practical relevance for psychodiagnostic assessment and psychotherapy. “forced” to prostitution. it could take her over 24 hours to get over things. Under-Regulation of Affect Under-regulation of affect could be operationalized as being over-aroused and overwhelmed by emotion and not being able to modulate these emotions. on the other hand. Mentalized affectivity is a sophisticated kind of affect regulation that denotes how affects are experienced through the lens of emotional Self-reflexitivity and can be enhanced in psychotherapy (Fonagy et al. this may keep the person unaware of the affective experience as either being numb of overwhelmed. but as soon as she quitted therapy. 2002).regulation of affect or over control. (3) The inadequate communication of emotion (due to being overwhelmed) or the non-expression or -experiencing of affect (numbness) which increases the likelihood that one’s needs will not be responded to by others and therefore increases the likelihood of social isolation and/ or a pattern of quickly changing and emotionally instable social contacts (Gross. (2) accident-proneness (several incidents involving a recent severe car crash).

conversion and undifferentiated somatoform disorder. In an attempt to ward off the emotions and to protect oneself. Pelcovitz. Van der Kolk. Roth. Van der Kolk. Trijsburg. only cognitions and physical pains appeared to play a role in her life. what did you want from me?” After several weeks. but she had headaches instead. (6) Sexual provoking behavior. & Kidd. Zakriski. et al. & Simpson.. 33 years old. Krystal (1988) referred to this “affect phobia” as “affect intolerance”. Ford. 1996. group members and staff became frustrated with her. (3) Having difficulty handling aggression. She rarely talked about relations between her behavior and emotions and she found it extremely difficult to elaborate on emotions when explicitly asked for. These features form the core of the alexithymia concept (Taylor et al. Bolk. Wolfsdorf & Zlotnick. Roth. and interpersonal problems with her family and colleagues. Rooijmans. 1996. (5) Suicidal pre-occupation. 1997) and have already been described in patients with medically unexplained physical complaints (Kooiman. Shea. During group therapy she did `not know what to tell about herself to group members. In dealing with everyday problems she did not have any clue about her emotions. (4) Having difficulty handling self-destructive impulses. Patients suffering from over-regulation may be characterized by the following features: (1) Being numb or inhibited.. with somatization disorder. Over-Regulation of Affect Over-regulation of affect can be described as being afraid to feel or experience emotions.and affect dysregulation Vignet: Miranda. the emotional system becomes numb. Costello. admitted at the Waard with dysthymic complaints. Mandel. (3) Having difficulty verbalizing emotions. Zlotnick. The above symptoms of under-regulation are characteristic of patients with borderline personality disorder (Linehan. 1997. Brand. & Mandel. 1998. Newman. Pearlstein.Patients manifesting under-regulation of affect may be characterized by either of the following: (1) Being overwhelmed by emotions. 1997). chronic pain disorder. A remarkable feature was her severe nail biting and her frequent up and down pacing. She often did not understand why people got so angry at her: “I did not do anything. . 2001. physical pains. Pelcovitz. and stuck to factual information of her experiences. 2000). & Resick. and (4) Having difficulty analyzing emotions. the inability to tolerate or experience emotions. (2) Suffering from impairments in insight into emotions. 1993). Emotional experiencing seemed lacking. Begin. (2) Being over-aroused. Chapter six 83 The clinical assessment and treatment of trauma-related self. PTSD and complex PTSD or DESNOS (Van der Kolk.

as the emotional signals keep them pre-occupied with their own experiences of inhibition or hyperarousal. patients suffering from affect dysregulation have difficulty to analyze other people’s emotions or to elaborate on them. She risks becoming the scapegoat in groups. 2000). to see the world through other people’s eyes. 1991. while receivers must be able to grasp the message that has been sent. During group therapy she was unable to attune emotionally to others and showed little empathy towards others in emotional situations. Leslie & Frith. This capacity is deficient in patients whose parents lacked empathy and emotional responsiveness. Fonagy and Target (1996) use the term Theory of Mind to refer to the capacity to understand mental states in the Self and Others. She was diagnosed with dysthymic disorder. Ann suffered from emotional numbness. 1988). the developing child is able to view the environment from the perspective of Others. In addition.” a reduced ability to understand the content and function of other peoples’ emotional mental life. it is difficult to recognize others’ facial affective expressions accompanying the emotional experiences (Baron-Cohen. Baron-Cohen. was presented to the clinical psychotherapy department by her partner. a phenomenon called egocentrism. 1985). aged 46 years old. the process by which a person responds affectively to another as if he or she were experiencing the same affect (Baron-Cohen. Infants view their physical and social environment in terms of the Self. 1995. For many psychiatric patients. lacked the capacity of empathy and her recognition of emotional facial expressions was poor. Affective reciprocity requires attuned empathy. This ability also includes perspective taking and is crucial for the ability to communicate and engage in reciprocal social interactions (Wenar & Kerig. The partner reported also interpersonal problems.Vignet: Ann. They seem to have a diminished emotional “mindsight. 84 Affective Reciprocity Reciprocity requires a finely tuned give-and-take between individuals. Senders must adjust their messages to what they infer to be the receivers’ level of comprehension. in particular enmeshed (family) relations. She failed to understand what other people experienced and seemed to stick to externally oriented thinking. . She had several quickly changing relationships that usually ended with fierce arguments. however. and complained of physical pains. Gradually. Others considered her as being blunt and confronting. This leads to a disturbed interpersonal emotional functioning and diminished empathic functioning.

insecurely regulated persons will never meet the sense of personal efficacy. Moreover. negative psychoform dissociation. dropped out of these kinds of treatments. positive somatoform dissociation. it is also considered to be an important factor in pertaining -. These insecure attachment based Self regulation strategies are an important factor in the explanation (1) why psychopathology and psychiatric disorders can develop and may become chronic. 2003). and an anxious & preoccupied adult attachment style characterized by interpersonal clinging behavior. positive psychoform dissociation. two distinct insecure attachment based Self regulation strategies are proposed: (A) De-activating Self Regulation Strategies and (B) Hyper-activating Self Regulation Strategies. q. when confronted with internal or external adverse events. De-activating Self Regulation Strategies encompass: over regulation of affect. Hyper-activating Self Regulation Strategies encompass: under regulation of affect. recidivist . Consequently leading to an “Insecure cognitive emotional information processing and insecure attachment based De-activating Self regulation strategies” vicious circle. but patients do not report this information easily. Chapter six 85 The clinical assessment and treatment of trauma-related self. which in turn conditions and upholds the insecure attachment representation. . Elaborating on Mikulincers’ attachment based hyperactivating and de-activating affect regulation strategies (Mikulincer et al. Often these disturbed patterns of affect regulation c.Attachment trauma related Self regulation strategies The clinical need to diagnose patients’ affective styles makes especially sense when treating patients who failed to respond to regular treatment protocols.or chronic psychopathology. affective styles have been established early in life and consequently often mistaken as temperament or personality traits.. negative somatoform dissociation. Consequently leading to an “Insecure cognitive emotional information processing and insecure attachment based Hyper-activating Self regulation strategies” vicious circle. or who suffered from complex and recurrent psychopathology that current treatment protocols do not apply for. In this contribution affect dysregulation is not only considered a factor in the development of psychopathology. Anamnesis and hetero-anamnesis are useful when attempting to assess (changed) emotional behavior. and a dismissing adult attachment style characterized by interpersonal avoidant& dismissing or avoidant & fearful behaviour. resilience. which in turn conditions and upholds the insecure attachment representation. 2004). and optimism (Mikulincer & Shaver. and (2) why current treatment protocols seem ineffective as they do not consider the impact of insecure cognitive emotional information processing and insecure attachment based Self regulation strategies.and affect dysregulation Assessment and treatment of affect dysregulation as usual Specific well-validated instruments to measure affect dysregulation as a specific syndrome are currently lacking.

2001). 1993). Shaw. & Tellegen (1988)) or the State-Trait Anxiety Inventory (STAI. (1979)) or the Positive And Negative Affect Scale (PANAS. Moreover. 86 PRELIMINARY EXPERIENCES WITH ASSESSING AFFECT DYSREGULATION Given the lack of adequate instruments to assess the nature of affect dysregulation. Sensimotor Therapy for Processing Traumatic Memory (Ogden. Teasdale & Barnard. emotional functioning is observed and assessed by a multidisciplinary . These treatment approaches focus mainly on handling affect and managing emotional behavior. Watson. During a six-week period. Examples are the Skills Training for Treating Borderline Personality Disorder (Linehan. Parker & Taylor et al. neither of these instruments neither do assess affect dysregulation as a two dimensional mechanism.and affect regulation has been criticized for its neglect of the importance of social and environmental factors in the etiology and maintenance of psychopathology (e. These instruments measure the cognitive aspects of emotional dysfunctioning (alexithymia or over-regulation) and the emotional factors (impairments in emotionality and impairments in fantasizing) and social aspects (impairments in insight into other’s emotions and impairments in analyzing other’s emotions) of emotional (dys)functioning. Bagby.Frequently applied instruments for the assessment of affective pathology such as the Symptom Checklist (SCL-90-R. Rush. The concept of alexithymia and emotional functioning can be more fully measured with the Bermond-Vorst Alexithymia Questionnaire (BVAQ. The aspect of over. Gorsuch & Lushene (1970)) all fail to capture the regulatory aspects of emotional experiencing. we have introduced a clinical observation period.. Affect Management group therapy for PTSD (Wolfsdorf & Zlotnick. 1993). Vorst & Bermond. 2001) and the EMOtional development Questionnaire (EMOQ. this instrument measures only the cognitive aspects of emotional dysfunctioning. However. Although these instruments make it possible to differentiate between subtypes of alexithymia. The advantages of a clinical monitoring system for assessing emotional functioning involve a prolonged monitoring of emotional behavior in interpersonal situations. Clark. 2000). Spielberger. Vorst & Bermond. we emphasize the observation of the quantity and quality of interactions with the staff and other group members. Derogatis (1994)) or the Beck Depression Inventory (BDI. & Emery. unpublished paper).regulation of affect or alexithymia is often under diagnosed or neglected. Beck. in particular: under-regulation of affect. 2003). Elaborating on that critic. Currently most affect-focused therapies focus on just one form of affect dysregulation. 2001). specific treatment protocols for the treatment of affect dysregulation are scarce (Greenberg & Borger. Managing Intense Emotions and Overcoming SelfDestructive habits (Bell.g. The pure individual and “intrapsychic” view on psychopathology and Self. The concept of alexithymia can be measured with a well-validated self-report instrument: the Toronto Alexithymia Scale (TAS. 1994).

g. applying specific observation rating scales for each discipline (see Table 1). Cassidy & Shaver. Each discipline has developed its own emotional functioning assessment instrument. and (3) Arousability and control concerning expressed emotions. Table 1: Multi-disciplinary therapy indication forms DISCIPLINE SOCIO THERAPISTS PSYCHOMOTOR THERAPIST MUSIC THERAPIST CREATIVE THERAPIST PSYCHOTHERAPIST INSTRUMENT SOCIAL FUNCTIONING OBSERVATION FORM Chapter six “EMOTIONAL BODY” scale MUSIC THERAPY EMOTION SCALE COLOR EMOTION OBSERVATION SCALE EMOTIONAL FUNCTIONING & GROUP-PSYCHOTHERAPY INDICATION FORM 87 The clinical assessment and treatment of trauma-related self.g. Siegel. In the pre-therapy observation period information about intrapsychic and interpersonal functioning is obtained on three aspects of affective functioning: recognition.and affect dysregulation To capture the nature and scope of affect dysregulation. 2001a. Ekman (2003)) as well as (2) a pre-therapy observation procedure (qualitative assessment). 1994. The assessment procedure encompasses (1) a psychodiagnostic therapy-oriented assessment procedure (quantitative assessment). self reports. (2) Interpersonal affective behavior. and computerized cognitive-emotional information processing tasks (e. These rating scales are an attempt to give a more objective description of what. the capacity to find a balance between control over emotional behavior and arousal/ excitement accompanying emotions. 2002. all interpersonal actions between withdrawal and approach. recent insights in the fields of affective neuroscience. focusing on their specific target of emotional dysfunction (see Table 1). ranging from comfortable (positive) to indifference or unwanted (negative). These rating scales reflect the collective sense of the different professions and they were constructed by collaborative actions (Smeijsters. facial affect recognition. Solomon & Siegel. 2001b. Schore. 1999. interpersonal emotional behavior and verbalized “hot cognitions” (Teasdale & Barnard. 1993) representing mood congruent memory and context-specific encoding and retrieval of autobiographical .clinical team. Below we elaborate on these dimensions. attachment theory. and mother-infant interaction were integrated in an assessment procedure (e. has been a clinical impression based on findings during pre-therapy observation sessions. Within the experience of affects the following three dimensions can be discerned and assessed: (1) Validation of emotions. consisting of clinical structured interviews. (1) Validation of emotions During patient-staff-meetings the staff can observe emotional expression. expression and experiencing of affects. until now. 2003). 1999. 1994a/1994b. 2005). Griffin & Bartholomew.

what preceded and/or what caused the situation or feeling. In addition. analyzing emotions and the capacity to express oneself in form and color is observed and explored. and emotional Self-reflexitivity while maintaining a sense of agency is assessed.. During psychomotor therapy the physical manifestations of emotions during interpersonal encounters and the (in) ability to “read” these manifestations (recognition of affect) are the main focus of attention (Taylor. emotional reciprocity. because they may be overwhelming. During psychotherapy sessions. 2000). 1993). This part of the assessment focuses on the ability to regulate the arousal levels and the ability to physically recuperate from emotions. 1994b) and Bowlby (1988) by interpreting patient’s interpersonal behavior in terms of secure or insecure attachment behavior. the ability to recognize the physical manifestations of emotions are evaluated (Rothschild. Often patients are afraid to experience these physical manifestations of emotions. the focus is on interpersonal similarities and differentiation in affect regulation (Linehan. what are the consequences of all these aspects for the near future. In addition. Each color stands for a particular emotion.g. Patients are invited to experience links between these physical cues and specific emotion and/ or accompanying cognitions. and how do they relate to others in the situation. Attachment clinging behavior and attachment . while at the same time the capacity to identify emotions and differentiate between emotional states (Smeijsters. This way through non-verbal cues patient’s capacity to reflect on their emotions and autobiographical situations is assessed. how do others comprehend this situation. differentiating between emotions. how does it manifest itself to you. et al. 88 (2) Interpersonal affective behavior Psychotherapists assess adult attachment style as described by Griffin and Bartholomew (1994a. dissociation) are activated.g. Emotional reciprocity involves listening to other people’s stories and being able to react empathically toward group members’ experiences or “emotional blind sight”. psychological defense mechanisms (e. it may encompass sharing stories while experiencing the accompanying feelings without being overwhelmed or being numb in interaction with other group members. Moreover..events which are involved in coping with current personal problems and dealing with emotions in relation to other group members. et al. and so on (Fonagy. To stimulate the process of validation of emotions. 1997). During creative therapy the capacity of identifying emotions. numbing) and attachment based maladaptive affect regulatory mechanisms (e. 2005) is assessed. Emotional Self-reflexitivity includes for example putting emotional experiences in a time-perspective. and how do they react to the situation and/or how do they feel. Instead. 2002). the patient’s capacity to integrate experiences and to verbalize emotions in relation to other group members’ and/or shared experiences is assessed. This way the quality of the process of mentalized affectivity. a color calendar is drawn every week and analyzed by means of a color evaluation system.

patients are invited to choose an ego-matching instrument and play it or make sounds. Between therapies. as in a small orchestra and the instruction is repeated. They have access to information concerning daily pathological and normal behavior and interactions. patients are invited to play the instruments or make sounds. Often. 2003). First. this second invitation is a difficult task to perform. Maladaptive affective behavior (such as the incapacity in an interpersonal context to modulate and regulate emotions) is explained in terms of attachment based affect regulation strategies. These strategies encompass hyperactivating strategies or deactivating strategies of affect regulation. whereas attachment clinging behavior is associated with “fear of abandonment”. Chapter six 89 The clinical assessment and treatment of trauma-related self. Attachment avoidance behavior is typically accompanied by “fear of closeness” and a “desire for independence”. 1957). 2005). and affective mentalizing. resulting in interpersonal withdrawal (avoidance) or approach (clinging) (Mikulincer. they can observe the way patients try to regulate emotions by interpersonal withdrawal or approach. On top of this the patients were asked to reflect on questions as: where do they fit in? Which group member can be of help in overcoming their difficulties? Which group member can be an obstacle in meeting therapy goals? How to cope with that? Etcetera. This insecure attachment behavior. is described on the basis of observation of the patient’s capacity of affective reflective function. Sociotherapists observe the patients’ affect regulation related behavior in between therapy sessions and during their everyday activities. et al. . 2002). and empathy (Fonagy... patients are invited to switch instruments and choose the instrument with opposite or incompatible characteristics. and/or by means of musical instruments. emotional perspective taking.. In both cases there is a “lack of interpersonal trust” (Griffin & Bartholomew. This interpersonal position awareness embraces the function of reflection. 1994b). et al.avoidant behavior are typical examples of insecure attachment. Again.and affect dysregulation (3) Arousability and control over expressed emotions In music therapy attention is directed towards the (in) capacity or blockage of the expression of emotions in vocal sounds. The instruction is to start at the same moment and after about twenty minutes again to stop simultaneously. in combination with the patient’s positive or negative verbalizations about the Self in relation to the Other helps unraveling the patient’s core beliefs if “help” or “harm” can be expected from the Other in times of distress or danger. et al. The (inter)personal emotional functioning. 2003). Emotional blockages and incapacity to make sounds are common reactions for these patients (Smeijsters. as in a small orchestra. patients are asked to reflect on the different positions they take in Leary’s Rose of Interpersonal Functioning (Leary. Next. It is often observed that their emotional behavior is fixated in one way of expressing emotions: (1) under regulation: hyper-activation of affect and emotions or (2) overregulation: de-activation of affect and emotions (Mikulincer. Concerning the relationship with other group members.

Interaction style was based on adult attachment styles using the Relationship Styles Questionnaire (RSQ. Finally. Consequently.g. & Williams. the patients have to write a “motivation-for-treatment” paper in order to be admitted in the clinic or day-clinic. e. affective and social aspects of emotional functioning. and (3) Arousability and control concerning expressed emotions.. Traumatic events and their impact on current functioning was assessed using the Traumatic Events Checklist (TEC. Spitzer. all interpersonal actions between withdrawal and approach. In order to improve compliance to psychotherapy. The DSM-IV-TR disorders are assessed using standardized clinical interviews. (2) Interpersonal affective behavior. Bernstein & Putnam. Spinhoven. Vorst and Bermond. 2002) measuring the cognitive. Patients orient themselves in the way that they think inpatient therapy at this particular ward will be “of use” to them. and automutilation are meant as affect regulation strategies or mood management. Van Dyck.nl. 2002). These include the following: Affect dysregulation and interpersonal emotional functioning is assessed by using the EMOtional functioning Questionnaire . ranging from comfortable (positive) to indifference or unwanted (negative). the Structured Clinical Interview for DSM IV axis I disorders (SCID-I. Nijenhuis. Van der Hart & Kruger.. the capacity to find a balance between control over emotional behavior and arousal/ excitement accompanying emotions are integrated in a psychotherapy-oriented assessment procedure at the department of (neuro)psychological assessment for therapy indication at our clinical psychotherapy ward. 2003). engagement in computer games. Van der Hart & Van der Linden. the patient is asked to write down realistic therapy goals that will be focussed on during psychotherapy and that are objective enough to evaluate therapy success with. Gibbon. cigarette smoking. 90 . 1993) for DSM-IV-TR axis II disorder. the patient’s motivation for treatment and engagement is challenged and assessed. First. patients are asked to prepare their personal evaluation of the ”pre-therapy/ Observation and Orientation period” at the Waard. 1997). Nijenhuis.56 items (EMOQ-56. 1994a). The (1) Validation of emotions. The concept of somatoform dissociation was measured by using the Somatoform Dissociation Questionnaire (SDQ-20. 2002). World Health Organization. Griffin & Bartholomew. 1999) and the concept of psychoform dissociation was measured using the Dissociative Experiences Scale (DES. et al. a number of self-report measures are administered tapping signs and symptoms of Self dysregulation. and the Dutch self report version of the Structured Interview for Disorders of Extreme Stress (SIDESr. Moreover. In addition.attachment based affect regulation strategies (Mikulincer. skating. and the International Personality Disorder Examination (IPDE. 1986). Van Dijke & Van der Hart. It is often observed that several behaviors.

a creative therapist. “You think you have everything under control. Characteristic for these complex pathology patients are the very different disorders on DSM-IV-TR axis I and axis II. Important therapeutic techniques are psycho-education on affect regulation styles. Affect regulative interventions concern both over-regulation as in: “stop thinking …. reflecting a balance between structure and flexibility. psychotherapists. lending you a hand to help you…. and evaluating therapy process are important instruments. followed by a 4-daytime or 3-daytime program. a social worker. Transference Chapter six 91 The clinical assessment and treatment of trauma-related self. information is provided about other people’s emotional perspectives. resulting in an out-patient group therapy program. consisting of a psychiatrist. All therapists working at “the Waard” are part of multi-disciplinary team. and learn how one’s (emotional) actions elicit reactions in the others and vice versa (social learning). To stimulate meta-cognitive processing. a music creative therapist. he is supportive and not neutral towards the patients in complex interpersonal conflicts. “I could imagine that you would not only feel mad about this but also disappointed or even sad”?) to facilitate new insights in a gentle way. are clear therapy goals and boundaries.and focus on the emotion and experience your emotion instead!” Another important aspect of interventions is pointing out interpersonal misinterpretations based on insecure attachment cognitive emotional information processing e. Characteristic for the therapeutic environment the patients live in.and affect dysregulation . Moreover.g.PRELIMINARY EXPERIENCES WITH THE AFFECT DYSREGULATION TREATMENT PROGRAM The focus of the treatment program is aimed at changing affect regulation styles and adult attachment styles which negatively influence interaction with significant others. a clinical psychologist. pointing at you! Where “help” is offered. The reflective function is stimulated by inviting the patients to actively mentalize one’s own and the others’ state of Mind and by (emotional) perspective taking. An important technique is also the stop-rule. Intensive in-patient therapy in groups seems to be the best fitting setting to learn from own observations of other patients. and affect mirroring. In the beginning of therapy. the therapist reflects more actively the patients’ perspective. raising her hand with a knife in it.. “passing the silver butler tray” ( to give meaning to behaviour and to suggest alternative thoughts and feelings. In order to do so we designed an in-patient program. modelling. you expect “harm”!” The psychotherapist’s style can best be characterized as active and interactive. but your mind tricks you! The therapist is reaching out to you. instead you interpret this reaching out as if she was reaching for you. Characteristic are the malign interpersonal patterns on DSM-IV-TR axis IV. a psychomotor therapist. keeping notes from therapeutic impressions and progression. and ward nurses. and focus on the emotion and experience your emotion instead!” and under-regulation as in: “stop acting ….

and a family member/ partner evaluate their experiences and findings during this O&O period.transference are exploited in the sense that the therapist interprets and explains these interpersonal dynamics in terms of interpersonal or dyadic affect regulatory phenomena to the patients and the accompanying cognitions. Moreover. knowledge about one’s emotions and cognitions . Behaviours such as drug abuse. The motto ”attachment is the dyadic interactive regulation of emotions. The therapist and group members each have their contribution to the Interpersonal Interpretative Function of group therapy (Fonagy. alcohol abuse. Together with the patient a conclusion is reached: staying for treatment or referral to another facility. 92 In the program the following phases can be distinguished: Phase 1: Patients engage in a six week “Observation and Orientation” (O&O) period at our ward. 2000).” is held (Sroufe. By emotional perspective taking and shared mentalized affectivity (Fonagy. et al. 1993). Group interactions in the here and now are elaborated on in terms of affect dysregulation. et al. At the end of this O&O period. 2002).. They are invited to explain their symptoms from an interpersonal developmental perspective and to share their (new) treatment goals with the group. 1994) and consequences for current interaction patterns (Leary. the concept of affect dysregulation is explained. they are thought to distinguish over-regulation and under. attachment representation. All other group members also present and explain their therapy goals and describe their therapeutic developmental process and therapy progress.and counter.. They also take part in an extended assessment procedure. are considered as signs of malign affect dysregulation (Linehan. 2002). Phase 3: The focus is on recognizing and discerning one’s own dysregulation of affect styles in different situations. The multi-disciplinary team members motivate patients to formulate therapy goals in terms of affect dysregulation (Paivio & Laurent. as well as about the quality of the therapeutic relation from previous therapists is collected after signed informed consent.. In other words: they are verbalizing and explaining their personal therapy rationale to the other group members. and adult attachment style. Through psycho-education. 1996). the patient. engaging in unsafe sex etc. adult attachment style (Griffin. signs and symptoms of affect dysregulation specified in under regulation of affect and over regulation affect are elaborated on. Before entering the program. 2001). Both parties make up a therapy contract and sign it. but a syndrome that can be treated. 1957). Subsequently. et al. information about the patient is gathered by means of our intake procedure. Phase 2: During this first “therapy” phase patients join in the therapy groups they are assigned to. the multi-disciplinary team. Patients learn that “affect dysregulation is not a way of life” (Chefetz.regulation of affects in Self and Others. automutilation. The concept of affect dysregulation is focussed on as a provoking and /or maintenance factor in chronic and complex anxiety and/ or affective and/ or somatization disorders... Information about previous therapies and therapy-effect or dropout.

etc). New perspectives are visualized and verbalized as metaphors. there is attention Chapter six 93 The clinical assessment and treatment of trauma-related self. 2002). This phase seems easy but is actually very difficult. Affect regulation is a process of crafting mental states in accordance with a sense of agency (Fonagy.. an evaluation of therapy process and progress of the patient is drawn up by the multi-disciplinary team (now using the multi-disciplinary therapy scales to monitor therapy progress and effect) and the fellow group members. attachment trauma. When there is no significant improvement and therapy progress. In the here and now through the dyadic relation with the therapist and triadic relation with the therapy group and the psychotherapist. Consequently. The family and social network are not familiar with the new representation of the patient’s Self and interact with the patient and appeal to the patient as if changes in personality have never occurred. Phase 4: After the mourning has been processed adequately. which results in the development of maladaptive cognitive-emotional information processing and maladaptive emotion regulation strategies. listen to calming or playful music. they understand that affect dysregulation is indeed not a way of life: there is another way of living! Phase 5: At this point. Mourning about missed feelings of love and secure attachment relationships earlier in life is addressed and processed. Phase 6: During outpatient therapy the focus is on reintegration in the patient’s home environment. When affect regulation and Self-regulation has improved. In order to understand themselves. an exposure program to potentially affect dysregulative situations in and around the clinic is carried out. followed by new more adequate Self regulation behaviour (take a walk. 2002). and “to let the anger come and go”.can be improved. losses are counted and it is evaluated what went wrong. The more the patient spends time at home the more the home environment provides cues to relapse into old habits. either the patient is referred to another clinic or the patient and the therapist formulate new therapy goals and therapy process is continued and re-evaluated after a month. Mindfulness based techniques are useful to accept recurrent feelings of rage and anger. the Interpersonal Interpretative Function might be re-established. So in order to stick to the new representation of the patient’s Self. the focus is on the here and now. A therapy effect assessment and a therapy-session with partner or parents is added. The aim is to engage in these situations. resulting in improved cognitive-emotional information processing and improved emotion regulation strategies. If improvement and therapy progress is clear and significant the treatment program has been successful and a referral to our day-time clinic or outpatient therapy is appropriate. Early adverse interpersonal experiences might explain why the dyadic relation with the attachment figure is frustrated and the Interpersonal Interpretative Function is ill developed (Fonagy et al. A self-regulation training based on affect tolerance is the new focus for therapy. in an attempt to measure and objectivate therapy results in terms of therapy process and therapy progress. At the end of this phase patients should have found a new balance in affect regulation and interaction. while maintaining the reflective function..and affect dysregulation . et al.g. patients learn to relate affect dysregulation styles to early adverse interpersonal experiences e.

Patients subsequently might be referred to either maintenance therapy or relapse prevention therapy. Sandra Visser and “Eikenboom” centre for psychosomatic medicine at Altrecht Mental Health/ Zeist/ the Netherlands. The assessment program has been proven to be successful and helpful in indicating patients for treatment and in assessing treatment progress and treatment effect. Finally. .4 4 The author wishes to acknowledge the multi-disciplinary team from “de Waard” centre for multi-disciplinary inpatient psychotherapy at Delta Psychiatric Hospital/ Poortugaal/ the Netherlands. dr. We discussed the relevance of clinical assessment and treatment of Self dysregulation and affect dysregulation in a psychiatric hospital.D.regulation and over-regulation of affect and treatment possibilities. After new cognitions and new emotions have been integrated in the representation of the self. in particular Annelies Plekker. On top of that. The aim is to maintain the reflective function according to the new representation of the Self while experiencing a sense of agency. day-clinic and outpatient setting was outlined. more specific under. Our approach is characterized by its multidisciplinary background. Next to having outlined the theoretical background and the rationale of our assessment procedures and treatment program. PhD. an integrative psychotherapy program encompassing a multidisciplinary therapy program in clinic. A psychotherapyeffect-assessment takes place. 94 CONCLUSION In this contribution the concept of affect dysregulation was redefined. patients are invited to maintain contact once a year to monitor affect regulation skills and to assess long term psychotherapy-effect. University of Tilburg/ Tilburg/ the Netherlands for reviewing a previous version of this contribution. in particular Martina Bühring. M. Phase 7: During this phase therapy process and progress is evaluated. M. Therapists of different disciplines collaborate in inpatient therapy sessions in order to assess signs and symptoms associated with affect dysregulation. At the end of this phase.Sc.. patients are supposed to be ready to “find a new way of life”. for their collaboration and contributions in the development of the presented assessment and treatment procedure and Prof.. some typical cases were presented. exposure therapy to potential affect dysregulative situations in the home environment takes place. Ad Vingerhoets.for the improvement of self-regulation by counter-conditioning old beliefs about the Self in relations to others.

Chapter seven Discussion .

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However. while clinically significant under-regulation and combined dysfunctional IE-regulation were associated. three different forms of dysfunctional self and affect regulation can be empirically identified: dysfunctional Inhibitory. inhibitory regulation was prominently reported. Excitatory.AND OVERREGULATION When combining the results from all the studies included in this thesis. The first conclusion that can be drawn is that under. Moreover. While under-regulation is moderate to strongly related to positive and negative psychoform and somatoform dissociation. dysfunctional affect regulation (specifically overregulation) may be less prominent as a clinical characteristic of SoD than prior studies have suggested. particularly those diagnosed . and combined Inhibitory & Excitatory (IE) regulation. commonly occurring in somatoform disorder (SoD).and over-regulation of affect. Secondly. Thirdly. commonly occurred in comorbid BPD+SoD. Combined dysfunctional IE regulation. several conclusions can be drawn. over-regulation of affect and negative psychoform dissociation. assessment of positive and negative somatoform and psychoform dissociative symptoms and over-regulation and under-regulation of affect may have utility in characterizing clinical and phenomenological features of BPD. as hypothesized. over-regulation is weakly related to positive and negative psychoform and somatoform dissociation.and over-regulation of affect proved related but largely different phenomena. patients diagnosed with BPD and BPD+SoD reported more severely dysfunctional self and affect regulation when compared to SoD and PC patients. the support for excitatory and combined IE-regulation is stronger than the support for inhibitory regulation. can be understood as inhibitory regulation. And under-regulation of affect and positive psychoform dissociation. Chapter seven 97 Discussion THE ROLE OF CHILDHOOD TRAUMA-BY-PRIMARY CAREGIVER AND COMPLEX PTSD The fourth conclusion based on the findings in these studies is that childhood trauma-by-primary-caretaker is highly prevalent among psychiatric patients. can be understood as excitatory regulation. with BPD and BPD+SoD as hypothesized. Thus. although no disorder-specific form of dysfunctional affect regulation or dissociation was found. However. there is a wide range of intensity of both positive and negative somatoform and psychoform dissociative phenomena (self-dysregulation) and of under. When SoD patients reported dysfunctional self and affect regulation. and other psychiatric disorders (PC. Thus. SoD. psychiatric comparisons). respectively. but mostly at subclinical levels.SUPPORT FOR DIFFERENTIATING DYSFUNCTIONAL UNDER. which were differentially distributed across diagnostic groups. commonly occurring in borderline personality disorder (BPD).

and psychotic disorders. Thus. 2003). as described in Chapter 6. while also reporting the most extensive trauma histories. For a subsample of patients meeting diagnostic criteria for comorbid PTSD. the results of this study suggest that further clinical and research studies are needed in order to further the development of empirically-based clinical assessment and treatment protocols for trauma-related self and affect dysregulation in adults with a range of Axis I and II psychiatric disorders. Disorder-specific assessment and treatment methods and guidelines for SoD and severe affective. interestingly.and over-regulation of affect depending on the type and developmental epoch of the traumatization.’ where BPD+SoD patients report the highest mean score.and self regulation that were identified and examined in the present studies. Patients diagnosed with comorbid BPD+SoD most frequently (almost 40%) met criteria for CPTSD. BPD and BPD+SoD patients reported similar CPTSD symptoms. over-regulation of affect was significantly related to PTSD-symptom severity. by including patients of both genders and other diagnoses as well as BPD. Emotional abuse or neglect by caregivers was associated with more severe under-regulation of affect when this caregiver-caused trauma occurred in early childhood (ages 0-6 years old). except for subscale ‘alterations in one’s system of meaning. the present study demonstrated that CPTSD is not exclusively or always found with (and therefore not synonymous with) BPD. but no significant associations for under-regulation of affect. The fifth conclusion that can be drawn is that CPTSD can be distinguished from BPD and/or SoD. and that childhood trauma-by-primary-caretaker is differentially associated with under. anxiety. Almost a quarter of all participating patients met criteria for CPTSD. Thus. although a prior report with a smaller clinical sample of women diagnosed with BPD reported that CPTSD was present in all cases (McLean & Gallop. 98 .and under-regulation of affect in psychiatricallyimpaired adults. based upon different patterns of affect dysregulation.’ where BPD patients report the highest mean score. it appears that CPTSD may be differentiated from PTSD. and for BPD thus may be enhanced by the addition of approaches focused on the types of dysfunctional affect. childhood traumatic experiences with primary caregivers may play a role in both over. developmental epochs or trauma-byprimary-caretaker with PTSD-symptoms severity were found.with BPD. Taken all together. Trauma involving violations of bodily integrity was associated with more severe over-regulation of affect independently of in which developmental epoch this caregiver-caused trauma occurred. Thus. as well as from BPD and SoD. Symptoms of CPTSD were significantly and differentially distributed across diagnostic groups. and subscale ‘total somatic complaints.

PTSD.. psychopathology does not necessarily equate with inaccuracy of trauma memory reporting (Klewchuk. There might have been more under-reporting than over-reporting of these events due to the emotions that were evoked and the difficulty in handling these emotions and cognitions. However. family member) reports. and trauma history were all assessed using self-reports. clinical observations. could be informative for the BPD and BPD+SoD patients who reported both clinically significant psychoform and somatoform dissociation to objectivate whether these Chapter seven 99 Discussion . 2007). participants who did report early trauma-by-primary-caretaker experiences found it difficult to do so. due to the potential influence of current symptom severity.. to overcome this limitation. Mulholland. 1992). dissociation. When using self-report measures it may be that the diminished capacity to self-reflect (often observed in psychiatric patients) resulted in decreased scores on and interrelations within inhibitory regulation (over-regulation and negative dissociative experiences). psycho-physiological measures. Self-reports. especially retrospectively self-reported types and times of exposure to potentially traumatizing events and CPTSD symptoms. Overall. Herman. The addition of a structured clinical diagnostic interview for the DSM-IV dissociative disorders. which was not included in the study in order to minimize participant burden. at the beginning of treatment patients diagnosed with SoD or BPD+SoD often have impairments in self-reflection and tend to attribute psychological distress to physical complaints. hetero-anamnesis/family reports. but a longitudinal study following children with objectivated childhood trauma. or (semi) structured interviews that assess all presentations of dysfunctional regulation (both affect dysregulation and dissociation) could provide complementary information on inhibitory regulation. Therefore. or biological markers may contribute to the furthering of understanding dysfunctional regulation in psychiatric patients.g. imaging methods. Data were obtained from a psychiatric population consisting of clinically admitted psychiatric patients with persistent psychopathology. Other data sources such as collateral (e. trauma histories were checked with close-relatives with patients consent. could contribute to the furthering of our understanding and knowledge of developmental pathways to dysfunctional regulation and the development of mental disorders across the lifespan. In this thesis. McCusker. Almost 20% of the BPD and BPD+SoD patients reported both clinically significant psychoform and somatoform dissociation and may have had a comorbid dissociative disorder (Nijenhuis.g. In particular. Nevertheless. & Shannon. may be inaccurate under these circumstances. efforts were made (with patient consent) to confirm the reported traumatic events with close relatives. CPTSD.STUDY LIMITATIONS A primary limitation of the study is that dysfunctional affect regulation. 2004). Trauma history self-reporting may be hampered due to a psychological defense against remembering early childhood trauma-by-a-primary-caretaker and holding on to a “belief in a just world” (e.

fearful or neutral expression. more than SoD patients. the main findings of the thesis may be supported by studies not included in this thesis that focused on the relationship of diagnostic status and affect dysregulation to facial affect labeling. adult attachment fears. and insecure attachment that interfered with normal cognitive-emotional development. Experiences 100 . and fear of being abandoned by someone. ADDITIONAL SUPPORT FOR DIFFERENTIATING DYSFUNCTIONAL REGULATION AND THE CLINICAL ASSESSMENT AND TREATMENT OF TRAUMA-RELATED SELF AND AFFECT DYSREGULATION PROTOCOL. In BPD patients facial affect labeling is more impaired than in SoD patients. Internalized histories of chronic trauma-by-primary-caretaker during childhood (insecure attachment representations or working models) are hypothesized to (negatively) bias cognitive-emotional information processing (Van Harmelen. cognitive. give meaning to neutral faces by projection of insecure attachment-based negative affect. Also. However. However. Ford. 2010). particularly in an interpersonal context may be accepted. potentially neutral situations (see Figure 1: insecure cognitive-emotional-information processing) are evaluated as threatening.patients have reports of dissociation that also meet criteria for a dissociative disorder. et al. BPD patients mistook neutral for fearful faces Results seem to support that BPD patients. and somatic functioning for dysfunctional regulation. under review) suggest that the hypothesis of biased cognitive-emotional information processing. In the future. Van ‘t Wout. Difficulties facial affect labeling may be related to childhood adversities. This negatively biased cognitive-emotional information processing was assessed by testing the ability to decode emotional information from facial expressions which plays an important role in conveying negative or positive feelings. & Aleman.. Error pattern analyses showed that neutral faces were most often mislabeled as happy and least as fearful faces. As a result. the option of assessing for dissociative disorders should be included in the protocol. in contrast to affect matching or discrimination adds a verbal component and requires categorization by giving meaning to visual stimuli. but also activate dysfunctional regulation including interpersonal strategies related to fear of being close to someone. especially in an interpersonal context. especially in an interpersonal context. and executive functioning (see Figure 1). This categorization enhances assessment of type of errors made for facial affect labeling accuracy for faces displaying a happy. angry. and approach or avoidance action tendencies. internalized histories of chronic trauma-by-primary-caretaker during childhood (insecure attachment representations or working models) are hypothesized to not only negatively bias cognitive-emotional information processing. Preliminary results from ongoing research (Van Dijke. The scope of this thesis was restricted to the exploration of the interrelations between affective. Facial affect labeling.

are associated with a de-activation of the attachment system and fear of closeness in combination with inhibited affect (inhibitory regulation.inhibited Mentalization/ ED . C=cognition. R=reflective function. other and self-other relatedness” activating -when exposed to adverse or ambiguous/ neutral (interpersonal) situationsinsecure cognitive-emotional-information processing and dysfunctional regulation encompassing: mainly Inhibitory regulation A – over-regulation of affect and numbness and inhibition of emotion S .Emphasis on Self reliance Experience of proximity as non-rewarding/punishment Tendency to perceive the non-viability of proximity seeking De-activation of attachment system internalized history of trauma by primary caretaker Emphasis on Helplessness Sense of dependence & fear of being alone High costs for perceiving the viability of proximity seeking hyper-activation of attachment system e.Negative Psychoform Dissociative symptoms I .dorsal vagal dominance mainly Excitatory regulation A. Dysfunctional Regulation Operating in Vicious Cycles NB: A=affect. Mikulincer & Shaver.immobilizing action tendencies PF .Positive Psychoform Dissociative symptoms fearful I – Fear of abandonment/ preoccupied R – pseudo Mentalization/ exec disorientation ED . are associated with hyper-activation of the attachment system and fear of abandonment and aroused affect (excitatory regulation. PF= psycho-physiological. 2003 Chapter seven Insecure attachment representations containing information on “self. S .. B=behavior. S=soma..Positive Somatoform Dissociative symptoms .. whereas experiences associated with sense of dependence and fear of being alone. see Figure 1). 101 Discussion interpersonal difficulties & psychological difficulties confirming Insecure attachment representations Figure 1.narrowing executive function B . I=interaction. C . ED=exec dysfunction.overly executive (haording) disoriented B – mobilizing action tendencies both PF – sympathic system dominance mainly Combined . lines in lightprint are not included in the thesis associated with proximity to the attachment figure as non-rewarding or punitive.Fear of closeness/ dismissive R .Negative Somatoform Dissociative symptoms C . see Figure 1) in the here and now.g.under-regulation of affect and intense and overwhelming emotion . Potentially leading to interpersonal difficulties that confirm and uphold insecure attachment representations/ working models and negative biased .

. SoD was associated with inhibition or denial of fears of abandonment or closeness. Egger. The findings from ongoing research (Van Dijke. Cook. Amrhein. Van der Hart.. Blankenburg. but weakly associated with under-regulation of affect and not to fear of abandonment. psychoform and somatoform dissociation were not present in all BPD or SoD patients.g. Comorbid BPD+SoD was associated with underregulation of affect. and over-regulation of affect. and both fear of abandonment and fear of closeness. Chronic trauma-by-primary-caretaker makes children vulnerable for interference of normal neuro-developmental trajectories (e. 2001). 2005) have been associated with compromised executive functioning (see Figure 1). Courtois & Ford. BPD was associated with under-regulation of affect and fear of abandonment.cognitive-emotional information processing (vicious cycle. Zucker. Inhibitory symptoms of compromised executive functioning were also moderately associated with fear of closeness. Ong. & Vinogradov. & Ponsford. complex trauma (Gabowitz. under review) seem to support the main findings of this thesis: Under-regulation of affect was moderately related to fear of abandonment but weakly related to fear of closeness. Ford. While. positive and negative psychoform and somatoform dissociation with inhibitory and excitatory symptoms of compromised executive functioning also seem to support the main findings of this thesis. 2009. 2010). plan. but only with over-regulation of affect. dissociation (Aikins. over-regulation of affect was moderately related to fear of closeness but not to fear of abandonment. Dysregulated information processing interferes with regular multisensory integration and interplay between remote but interconnected regions of the human brain (Driver. et. it is of practical relevance to assess presence. 2008). see Figure1). Minzenberg. and insecure attachment (Ford. & Bühring. Van Son. 2001. Ford. & Ruff. & Ray. Poole. 2005). Bestmann. execute. Maragkos. Hengmith. Therefore. and monitor complex goal-directed activities (Bennett. Affect dysregulation (Barkley. clinical levels of under. . Lynch. Al. 2006.and over-regulation of affect. 2008). Compromised executive dysfunction is understood to refer to a constellation of neurobehavioral deficits. & Hennig-Fast. that may reflect a pattern of disorganized/ disoriented adult attachment. 2008). The preliminary results from this ongoing research (Van Dijke. Excitatory symptoms of compromised executive functioning were also moderately associated with under-regulation of affect and fear of abandonment but not to fear of closeness. 102 IMPLICATIONS FOR CLINICAL PRACTICE Although all patients reported some symptoms of dysfunctional regulation. under review) focusing on interrelations between two forms of dysfunctional affect regulation. Van der Heijden. arising from disruption to the higher-order cognitive processes required to initiate. Both inhibitory and excitatory symptoms of compromised executive functioning were moderately associated with positive and negative psychoform and somatoform dissociation.

” When dysfunctional regulation is apparently not present. Ford. Gergely.g. patients must be aware of their psychological burden and be somewhat “psychologically minded. Comorbid SoD in BPD patients or comorbid BPD in SoD patients seem to represent more complex symptom presentations than just comorbidity of two mental disorders. Jurist. as well as for PTSD. suggesting that this form of dysfunctional regulation does occur but is not typical in patients with BPD and/ or SoD. 2001. more extensive trauma histories. Also. treatment guidelines are needed for the large sub-group of such individuals with severe comorbiditywho have experienced trauma-by-primary-caretaker and present with complex traumatic stress symptoms in addition to the symptoms of BPD and SoD (Courtois & Ford. However. 2009). Wolfsdorf & Zlotnick. these patients also reported more and differential dysfunctional regulation symptoms. However. Transference Focused Psychotherapy (Levy et al. Also. resembles CPTSD. 2005... and more often met criteria for CPTSD. especially when also diagnosed with comorbid SoD or clinically significant somatoform symptoms. et al.. non-verbal assessment.. as outlined in chapter 6. Based on the main findings of this thesis. CPTSD-symptoms. 2006. clinicians and researchers should be alert for signs of the patient’s unawareness of inhibitory regulation. especially when comorbid with SoD. 2006). Ford & Russo. 2010). including Dialectical Behavior Therapy (Linehan et al. youth. for PTSD and CPTSD patients reporting difficulties with addressing and analyzing emotions or “mentalizing emotions” and negative dissociative symptoms (Fonagy. 2008). and CPTSD patients. the main findings of this thesis warrant additive assessment and treatment of over-regulation of affect and negative dissociative symptoms e..g. and Mentalization Based Treatment (Bateman & Fonagy. Lanius et al. the findings of this thesis warrant explicit assessment for CPTSD and the addition of a more trauma-focused approach.” Thus. Although BPD. inhibitory regulation seem to have been overlooked and may be of particular importance in the assessment and treatment of chronic childhood traumarelated pathology such as comorbid BPD+SoD or Complex PTSD (Ford. it seems warranted to thoroughly assess dysfunctional regulation. as was outlined chapter 6 of this thesis: The clinical assessment and treatment of trauma-related self and affect Chapter seven 103 Discussion . 2007). and dissociative disorders when patients are characterized by BPD+SoD comorbidity. Approaches to dysfunctional regulation have been developed for patients with severe mental disorders (adults.nature and severity of dysfunctional affect and self-regulation in BPD and/or SoD patients. patients (e. 2002). in order to self-report symptoms of dysfunctional regulation such as inhibitory regulation. Fewer than one in three patients reports experiencing IE-regulation. & Target. 2006). SoD patients) may be mainly bodily focused or present with a cognitive style described as “operative thinking. these treatments address under-regulation of affect more explicitly than over-regulation of affect. or projective assessment techniques may be useful aids to assess inhibitory regulation. Multi-informants reports. For BPD patients. In addition to meeting diagnostic criteria for both mental disorders.

and psycho-physiological functioning.. and Attachment. Globally. and phase 3: personality (re)integration and rehabilitation (e. If emotion-addressing therapy and emotion–skills training are implemented in treatment phase 1 (stabilization. that early developmental epochs are more vulnerable to the development of enduring dysfunctional affect regulation and dissociation compared to potentially traumatizing events later in . Gleiser. Dissociative Disorder Not Otherwise Specified there seems to exist some clinical consensus that phase-oriented treatment is necessary for these patients. & Ford.dysregulation. neurofeedback and (emotional) regulation exercises like yoga (Van der Kolk. Minton. Blaustein. phase 2: the integration (or processing) of traumatic memories. symptom reduction. For patients who report inhibitory regulation therapy forms like sensory-motor therapy (Ogden. selfor hetero-report. Self-Regulation and Competency (ARC. Nijenhuis. symptom reduction. addressing inhibitory regulation may even facilitate trauma-focused therapy (treatment phase 2). it has been established that chronic childhood trauma often is polymorph. further research regarding the differentiation of dysfunctional regulation is warranted. Herman. Courtois & Ford. In future such a clinical intrument and/ or battery of associated neuro-psychological-tasks should be developed and validated. somatic. Brown. 2006). could facilitate functional regulation and enhance therapy process and progress. and skills training. Kinniburgh. 2006). 2001. Also.g. 2009. & Pain.Paivio & Pascual-Leone. behavioral. Focusing on biological and psycho-physiological aspects of regulation and dysregulation was not included in the scope of the thesis but in future should embrace the differentiation of dysfunctional regulation (see Figure 1). & Hammond. However. Dissociative Disorder. stabilization. emotion-focused therapy for trauma (Greenberg & Bolger. For patients with histories of trauma-by-primary-caretaker and mental disorders like CPTSD. reflective. Even a more technical-emotional approach. 1992. 2009). 104 IMPLICATIONS FOR RESEARCH Based on the main findings of the thesis. relational. 2010). and skills training). task) is yet available that assess both inhibitory and excitatory regulation across several domains of functioning including affective. 2006). 2003. or virtual-reality social-emotional skills training and perspective taking (Blackmore. Spinazzola & van der Kolk 2005) could contribute to the experiential process of emotional awareness and emotional growth. 2010). executive. Phase-oriented therapy can be divided into three phases: phase 1. Van der Hart. interview. Fosha. And that chronic childhood trauma disrupts the normal developmental trajectories and has enduring effects on neurobiology. 2003). such as facial affect recognition skills training (Ekman.g. especially when this occurs in the first-family environment and/or when a caretaker is involved.. Paivio. Scheflin. accelerated experiential-dynamic psychotherapy (Fosha. & Steele. cognitive. no specific measure (e. 1998.

and psycho-physiological functioning could further increase our knowledge about trajectories of developmental injuries and differentially clinical presentations across the lifespan. neither the interview (SIDES) nor the selfreport for CPTSD (SIDES-SR) incorporated this differentiation for inhibitory and excitatory regulation. van der Chapter seven 105 Discussion . APA. based on the main findings of this thesis. However. also the DSM-IV speaks of “dissociative flashback episodes” as one of PTSD’s symptoms. relational. these studies did not systematically differentiate three forms of dysfunctional regulation. high co-morbidities on all DSM-axes). Van der Hart et al. 2006. cognitive. they did not and concluded that over-regulation was dissociative. executive. thereby acknowledging only negative dissociative phenomena to be dissociative. and the development of hormonal homeostasis and balancing. but also to positive dissociative symptoms. make patients vulnerable for being misdiagnosed (i. However. Intrusive PTSD symptoms that some authors regard as positive dissociative symptoms (e. somatic. based on this thesis’ main findings it may be concluded that dissociation does not just pertain to negative dissociative symptoms. reflective. It may well be that Lanius over-generalized the findings to be dissociative. and only Teicher’s (2006) study differentiated developmental epochs vulnerable for the development of selfand affect regulation. somatic.g. cognitive. behavioral. executive. However. and psycho-physiological functioning. it may be concluded that three qualitatively different forms of dysfunctional regulation do exist.. Longitudinal study of children with objectivated trauma-histories on the developmental pathways and differentiating dysfunctional regulation across several domains of functioning including affective. Furthermore. Also. nor included multiple symptoms of dysfunctional regulation. they proposed the dissociative sub-type of PTSD. 2004) were believed not to be dissociative but merely PTSD-criteria. Patients are able to distinguish between under. they are largely different kinds/types of phenomena. Based on the main findings of this study. it may be concluded that although under.and over-regulation are related to psychoform and somatoform dissociative symptoms. that can vary across the lifespan. The complex of dysfunctional self-regulation symptoms and associated scope of clinical presentations. an interview for Developmental Trauma Disorder (DTD. Recently..and over-regulation of affect as well ass positive and negative psychoform and somatoform dissociative symptoms. the development of sensorimotor awareness and capacities. relational. This could particularly focus on parts of inhibitory and excitatory regulation that were not included in the scope of the thisis: the development of mentalizing capacities. behavioral. Future imaging research should include differentiating dysfunctional regulation across several domains of functioning including affective. Lanius and colleagues (2010) in their recent neuro-imaging study found support for the presence of under-regulation and over-regulation in PTSD patients..life. and mistreated or fragmented treatment in the mental health system. However. in contrast to differentiating positive and negative psychoform and somatoform dissociative symptoms in this thesis.e. reflective.

and parent-. excitatory. teacher-. relational. . Dysfunctional inhibitory. when returning to figure 1 and the aims of the thesis. personal communication). Based on the results of those studies and the main findings from this thesis. and executive functioning. future research should focus on tests of criterion and convergent and discriminant validity of the interview in relation to children’s self-reported. Therefore. and observer-rated inhibitory. excitatory. Consistent with the findings of this study. somatic. affective. and combined IE regulation. the development of a tailor-made assessment and treatment protocol is warranted for patients with treatment-as-usual-resistant complex symptom presentation reporting potentially traumatizing events by-primary-caregiver as outlined in chapter six: The clinical assessment and treatment of trauma-related self and affect dysregulation. CPTSD is common in patients diagnosed with mental disorders. and Excitatory regulation is associated with emotional trauma especially when first occurring in the developmental epoch 0-6 years. especially when diagnosed with BPD-alone or comorbid with SoD. cognitive. 2005) for children and adults has been developed (Ford.and combined IE-regulation. SoD. excitatory. Thus. we can conclude based upon the main findings of this thesis and related performed studies that support was found for the existence of inhibitory-. this interview does incorporate symptoms that differentiate inhibitory and excitatory regulation as well as psychoform and somatoform dissociation. CPTSD can be differentiated from BPD and BPD+SOD. and combined IE-regulation in patients diagnosed with BPD. comorbid BPD+SoD and PC was found across several domains of functioning i.. 106 CONCLUSION Finally. adaptation of the adult CPTSD.interview and -self-report measures should be considered in order to systematically incorporate the assessment of the different forms of affect and self-regulation.Kolk.e. Dysfunctional regulation seems related to trauma-by-primary-caretaker: Inhibitory regulation is associated with physical trauma.

Summary .

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expressed in intense and unmodified forms. the relations with potentially traumatizing events-by-the-primary-caretaker while differentiating developmental epochs. Activation of dysfunctional regulation seems to follow trauma-by-primary-caretaker associated negatively biased cognitive-emotional information processing. it has been established that affect dysregulation is involved in the etiology of psychopathology and that dysfunctional regulation is often described in patients with complex psychopathology and mental disorders. somatoform disorder (SoD). cognitive.SUMMARY The aim of the thesis was to provide a systematic exploration of the nature and distribution of dysfunctional affect regulation. Dysfunctional regulation may present in patients in three qualitatively different forms: Inhibitory-. behavioral. and retrospectively reported potentially traumatizing events in patients diagnosed with borderline personality disorder (BPD). Whereas some patients react to adversities with inhibited experiencing and social withdrawal. comorbid BPD+SoD. However. Excitatory-. Despite a vast amount of research on the benefits of successfully regulating affect for our mental well-being. Consequently. and overwhelm reasoning: 109 Summary . Symptoms include disturbances in self-regulation across several domains of functioning including affective. and the distribution of complex PTSD associated symptoms in our study groups. However. dysfunctional regulation is activated false positively. its associated phenomena. this may result in interpersonal misunderstanding and disappointments. relational. and a psychiatric comparison group (PC) to provide a baseline against which to compare the hypothesized elevations in dysfunctional self and affect regulation. The BPD literature mainly considers dysfunctional affect regulation to be a deficiency in the capacity to modulate negative affect such that emotions become uncontrolled. the role of dysfunctional affect regulation for psychiatric patients remains unclear. cognition and soma. Van Dijke (2008) described dysfunctional self and affect regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective. others react hyperemotionally and tend to cling to a significant other to alleviate stress and regulate to baseline. and psycho-physiological functioning. Dysfunctional affect regulation typically seems to involve an interpersonal context and attachment theory has become a prominent conceptual framework for understanding the process of development of affect regulation and dysregulation. when potentially neutral situations are processed and evaluated as threatening or potentially harmful. which in turn condition and uphold the insecure attachment representation/ working models eventually turning into dysfunctional regulation vicious circles. executive. reflective. Two mental disorders that have been associated with dysfunctional affect regulation are BPD and SoD. somatic. The focus of the thesis will be on dysfunctional regulation domains affect. and combined Inhibitory & Excitatory (IE)-regulation.

such as dissociative parts of the personality (Van der Hart et al. Infants who additionally experience an abusive caretaker are at risk for developing post-traumatic states of enduring negative affect that may become disorganized attachment working models and chronic dysfunctional affect regulation patterns. BPD+SoD. and combined Inhibitory & Excitatory (IE) regulation. including feeling overwhelmed. the SoD literature considers affect dysregulation to be an inhibition of emotional awareness. respectively. Furthermore. which were differentially distributed across diagnostic groups. Childhood trauma-by-primary-caretaker has a special importance in the etiology of severe mental disorders such as BPD and SoD. representing inhibitory and excitatory experiencing. Such sequelae of early life “neuro-developmental injury” have been described 5 In the literature. seizures.under-regulation of affect. Both affect dysregulation and dissociation involve distinct mental states5. and frozen. Caretaker-related traumatic stressors are likely to occur in and contribute to a relational growth-inhibiting early environment. and may therefore adversely impact the development of affect regulation capacities in childhood. No disorder-specific form of dysfunctional affect regulation or dissociation was found.. these subsystems have received various names. SoD. Thus. 2006). 110 . Excitatory. Infants of caretakers who are unresponsive or poorly affectively attuned are at risk for developing insecure attachment. -some authors have considered BPD and SoD to be disorders of affect regulation.and affect regulation is considered a core component in BPD and SoD. However. As dysfunctional self. hyper-alertness. dysfunctional affect regulation is distributed differentially for BPD. expressionless. There is a wide range of intensity of both positive and negative somatoform and psychoform dissociative phenomena (self-dysregulation) and of under. despite apparent similarities between affect dysregulation and dissociation. machine-like. when dysfunctional regulation was present in SoD specifically over-regulation of affect was most reported. and difficulty handling intense emotion states. with BPD and BPD+SoD. Mental states associated with inhibited experiencing are consistent with over-regulation of affect and with the negative psychoform and somatoform dissociative symptoms. Three different forms of dysfunctional self and affect regulation can be identified: dysfunctional Inhibitory. and diminished capacities to recognize and articulate affects: over-regulation of affect. However.it is of empirical and clinical relevance to differentiate forms of dysfunctional affect regulation. and PC. surprisingly little is known about the specific interrelations between the two psychopathological phenomena. while clinically significant excitatory regulation and combined dysfunctional IE-regulation were associated. Mental states associated with excitatory experiencing are consistent with under-regulation of affect and with the positive psychoform and somatoform dissociative symptoms.and over-regulation of affect. including appearing emotionally constricted. While. dysfunctional regulation may be less prominent as a clinical characteristic of SoD than prior studies have suggested. impulsivity.

Moreover. specifically in BPD. Disorder-specific assessment and treatment methods and guidelines for BPD. somatization. The results of this thesis suggest that further clinical and research studies are needed in order to further the development of evidence-based clinical assessment and treatment protocols for traumarelated self and affect dysregulation in adults with a range of Axis I and II mental disorders. The consequences for theory and clinical applications are discussed. based upon different patterns of affect dysregulation. the present study demonstrated that CPTSD is not exclusively or always found with (and therefore not synonymous with) BPD.and self regulation that were identified and examined in the present studies. CPTSD can be distinguished from BPD and/or SoD. Childhood trauma-primary-caretaker plays a role in both over. and anxiety. Also. by including patients of both genders and other diagnoses as well as BPD. An example of the clinical applications for multi-disciplinary assessment and treatment is outlined. dissociation. This disorder fundamentally involves the focus of this study: dysfunctional affect regulation and dissociation. and shattered or altered basic beliefs. Although a prior report with a smaller clinical sample of women diagnosed with BPD reported that CPTSD was present in all cases. may be enhanced by the addition of approaches focused on the types of dysfunctional affect. as well as from BPD and SoD. but also other symptoms reflecting disturbances predominantly in affective and interpersonal self-regulatory capacities. Complex PTSD (CPTSD) was introduced as a clinical syndrome for adults. 111 Summary . In an attempt to capture the complex symptom presentation that includes not only posttraumatic stress symptoms. it appears that CPTSD can be differentiated from PTSD. SoD and severe affective. Adults who were exposed to potentially traumatizing events by primary caretaker during childhood often demonstrate complex psychological disturbances that are not fully captured by the Posttraumatic Stress Disorder (PTSD) diagnosis.and under-regulation of affect depending on the type and developmental epoch of the traumatization in psychiatrically-impaired adults. 2009).as epidemic and under-studied (Kaffman.

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Samenvatting .

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somatoforme stoornis (SomS). en in welke mate complexe PTSS-geassocieerde symptomen voorkomen in de studiegroepen. blijft de rol van disfunctionele affect-regulatie voor psychiatrische patiënten vooralsnog onduidelijk. en een combinatie van Inhibitoire. die vervolgens weer onveilige gehechtheidrepresentaties/ modellen conditioneren en bevestigen. de relaties met potentieel traumatiserende gebeurtenissen door de primair-verzorgende.en affect-regulatie en de lange-termijn gevolgen van trauma-door-eenprimair-verzorgende. Disfunctionele affect-regulatie komt in het bijzonder voor in een interpersoonlijke context. Het is wel bekend dat affect-disregulatie een rol speelt in de ontwikkeling van psychopathologie en dat disfunctionele regulatie veel voorkomt bij patiënten met complexe psychopathologie en psychische stoornissen. Hoewel door veel studies de voordelen van succesvol affect regulatie voor onze psychische gezondheid is aangetoond. Van Dijke (2008) beschreef vanuit een ontwikkelingsperspectief vicieuze cirkels van disfunctionele zelf. Hierbij wordt tegelijkertijd gedifferentieerd naar ontwikkelingstadia. relationeel. Echter. wordt disfunctionele regulatie onnodig geactiveerd (vals-positief negatieve interpretatie en evaluatie). Excitatoire regulatie (E).en Excitatoire(IE) regulatie. Disfunctionele regulatie kan in drie kwalitatief verschillende vormen voorkomen: Inhibitoire regulatie (I). plus een psychiatrische vergelijkingsgroep (PG). gedragsmatig.SAMENVATTING Het doel van dit proefschrift was om een systematische exploratie weer te geven van de kenmerken en de verdeling van disfunctionele affect-regulatie. als neutrale situaties worden geïnterpreteerd en geëvalueerd als bedreiging of mogelijk schadelijk. Dit kan leiden tot interpersoonlijke misverstanden en teleurstellingen. executief. De gehechtheidtheorie is daardoor een belangrijk conceptueel denkkader geworden om het proces van de ontwikkeling van affect-regulatie en -disregulatie te begrijpen. 115 Samenvatting . Symptomen omvatten verstoringen in de zelf-regulatie in verschillende domeinen van functioneren. uiteindelijk leidend tot vicieuze cirkels van disfunctionele regulatie. Waar sommige patiënten op tegenslagen verstild reageren en zich sociaal terugtrekken. geassocieerde fenomenen en retrospectief gerapporteerde traumatiserende gebeurtenissen door patiënten gediagnosticeerd met borderline persoonlijkheidsstoornis (BPS). het lichaam (soma).en affectregulatie mee vergeleken kunnen worden. somatisch. waaronder affectief. comorbide BPD+SomS. Activatie van disfunctionele regulatie lijkt te volgen op trauma-door-de-primair-verzorgende geassocieerde en negatief gekleurde cognitief-emotionele informatieverwerking. De focus van dit proefschrift ligt op disfunctionele regulatie op het domein van het affect. reflectief. reageren anderen hyperemotioneel en hebben ze de neiging zich te klampen aan belangrijke anderen om zo stress te reduceren en weer naar een emotioneel basisniveau terug te kunnen keren. de cognitie. en psycho-fysiologisch functioneren. waar de scores op het gebied van zelf.

Twee psychische stoornissen die geassocieerd zijn met disfunctionele affect-regulatie zijn BPS en SomS. Disfunctionele affect-regulatie komt in verschillende mate voor in BPS. hyper-alertheid. zodanig dat die het redeneren overweldigen: onderregulatie van affect.en affect-regulatie kunnen onderscheiden worden: Disfunctionele Inhibitoire (I). and moeite intense emotionele toestanden aan te kunnen. pseudo-epileptische aanvallen. en verminderd vermogen om emoties te herkennen en benoemen: over-regulatie van affect. mechanisch. Hoewel klinisch significante excitatoire regulatie en gecombineerde IE-regulatie zijn geassocieerd met respectievelijk BPS en BPS+SomS. en kunnen daardoor van negatieve invloed zijn op de ontwikkeling van affect-regulatie vaardigheden in de kindertijd. Mentale toestanden geassocieerd met excitatoire-beleven zijn consistent met onder-regulatie van affect en met positieve psychoforme en somatoforme dissociatieve symptomen. zodat het lijkt alsof ze emotioneel verstild. die op zich ook weer verschillend verdeeld waren over de diagnostische groepen. emoties worden ongecontroleerd en uitgedrukt op een intense. Kinderen 116 . Mentale toestanden geassocieerd met inhibitoire-beleven zijn consistent met over-regulatie van affect en met negatieve psychoforme en somatoforme dissociatieve symptomen. Er is geen stoornis-specifieke vorm van disfunctionele affect-regulatie of dissociatie gevonden.en excitatoire beleving representeren. Zowel affect-disregulatie als dissociatie heeft betrekking op verschillende mentale toestanden die inhibitoire. waaronder het zich overweldigt voelen door emoties. Excitatoire (E). uitdrukkingsloos. Er bestaat een brede range van intensiteit voor zowel positieve als negatieve somatoforme and psychoforme dissociatieve fenomenen (zelf-disregulatie) als voor onderen over-regulatie van affect. Indien disfunctionele regulatie aanwezig is in SomS. Omdat disfunctionele zelf. onaangepaste wijze. Drie verschillende vormen van disfunctionele zelf. wordt over-regulatie van affect het meest gerapporteerd. en gecombineerde Inhibitoire en Excitatoire (IE) disregulatie. Trauma-door-de-primair-verzorgende in de kindertijd is van bijzonder belang in de ontwikkeling van ernstige psychische stoornissen zoals BPS en SomS. en bevroren/ijzig zijn. impulsiviteit. De BPS-literatuur beschouwt disfunctionele affect-regulatie als een tekort in het vermogen om negatief affect te moduleren. BPS+SomS. Primair-verzorgendegerelateerde stressoren komen het meest waarschijnlijk voor in en dragen bij aan een relationele ontwikkelingsremmende vroege omgeving. is disfunctionele regulatie voor SomS minder prominent aanwezig dan vorige studies hebben gesuggereerd. In tegenstelling hiermee wordt in de SomS-literatuur affect-disregulatie beschouwd als een inhibitie van emotionele gewaarwording. en PG. Ondanks de ogenschijnlijke gelijkenis tussen dissociatie en affect-disregulatie. is er verbazingwekkend weinig bekend over de specifieke interrelaties tussen de twee psychopathologische fenomenen.en affect-regulatie wordt beschouwd als kerncomponent van BPS en SomS –sommige auteurs beschouwen BPS en SomS zelfs als affect-regulatie stoornissen . SomS.is het van empirisch en klinisch belang om te differentiëren tussen verschillende vormen van disfunctionele affect-regulatie.

blijkt uit het huidige onderzoek dat door toevoeging van mannelijke patiënten en patiënten gediagnosticeerd met BPS zowel als andere stoornissen. Daarnaast kan CPTSS worden onderscheiden van BPS en/of SomS. lopen het risico om een posttraumatische toestand te ontwikkelen. Deze stoornis heeft fundamenteel betrekking op de focus van dit proefschrift: Disfunctionele affect-regulatie en dissociatie. In de discussie volgt een uiteenzetting van de consequenties voor onderzoek en de klinische praktijk. werd de diagnostische categorie complexe PTSS (CPTSS) geïntroduceerd als klinisch syndroom voor volwassenen. afhankelijk van het type trauma en het ontwikkelingstadium waarin de traumatisering voorkwam. maar ook andere symptomen die voornamelijk betrekking hebben op problemen op het gebied van de affectieve en relationele vermogens. ernstige stemmings. Kinderen die in aanvulling daarop een mishandelende verzorgende hebben. Hoewel een eerdere studie met een kleinere groep vrouwelijke patiënten gediagnosticeerd met BPS rapporteerde dat CPTSS in alle gevallen aanwezig was.en zelf-regulatie zoals geïdentificeerd and onderzocht in de huidige studies.van verzorgenden die weinig responsief zijn of weinig emotioneel betrokken lopen het risico om onveilige gehechtheidrepresentaties te ontwikkelen. dissociatie.en behandelprotocollen voor trauma-gerelateerde zelf-en affect-regulatie bij volwassenen met een diversiteit aan as I en as II psychische stoornissen.en angststoornissen. Deze toestand wordt gekenmerkt door chronisch negatief affect met bijbehorende gedesorganiseerde gehechtheidrepresentaties/ modellen and chronische disfunctionele affect-regulatie patronen. 2009). In een poging om de complexe symptoom presentatie die niet alleen de symptomen van posttraumatische stress omvat. Zulke gevolgen van “neuro-ontwikkelingschade” in het vroege leven zijn beschreven als epidemisch terwijl zij tot dusver onderbelicht zijn gebleven (Kaffman. CPTSS kan op basis van verschillende patronen van affect-disregulatie niet alleen van BPS en SomS. CPTSS niet exclusief is of altijd aangetroffen wordt bij (en dus niet synoniem is aan) BPS. SomS. somatisatie en vervormde basis-veronderstellingen over zelf. maar ook van PTSS onderscheiden worden. Een voorbeeld van de consequenties voor de klinische praktijk in de vorm van multi-disciplinare diagnostiek en behandeling is beschreven. Volwassenen die zijn blootgesteld aan potentieel traumatiserende gebeurtenissen door de primair-verzorgende in de kindertijd laten vaak complexe psychische problemen zien die niet volledig omvat worden door de diagnose posttraumatische stress-stoornis (PTSS). Stoornis-specifieke diagnostiek en behandelmethoden en richtlijnen voor BPS. De resultaten van dit proefschrift laten zien dat meer klinisch en empirisch onderzoek nodig is voor de ontwikkeling van evidence-based klinische diagnose. kunnen verbeterd worden door de toevoeging van benaderingen die focussen op vormen van disfunctionele affect. Bij volwassenen met een psychische stoornis en in het bijzonder bij BPS speelt trauma-door-deprimair-verzorgende in de kindertijd een belangrijke rol in zowel over-regulatie als onderregulatie van affect. 117 Samenvatting . de ander en de toekomst.

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EEN WOORD VAN DANK Ithaka Als je de tocht aanvaardt naar Ithaka wens dat de weg dan lang mag zijn. Ithaka gaf je de mooie reis. met grote vreugde en genot zult binnenvaren in onbekende havens. dat je talrijke steden in Egypte aan zult doen om veel. zodat je als oude man pas bij het eiland het anker uitwerpt. verder heeft het je niets te bieden meer. De Kyklopen en de Laistrygonen. barnsteen en ebbehout. Zo wijs geworden. Wens dat de weg dan lang mag zijn. de woedende Poseidon behoef je niet te vrezen. zul je al begrepen hebben wat Ithaka’s beduiden. Houd Ithaka wel altijd in gedachten. opwindende geurstoffen zoveel je krijgen kunt. De Kyklopen en de Laistrygonen. met zoveel ervaring. Was het er niet. heel veel te leren van de wijzen. p. Ithaka bedroog je niet. en verfijnd de emotie die je hart en lijf beroert. zonder te hopen dat Ithaka je rijkdom schenken zal. dan was je nooit vertrokken. rijk aan wat je onderweg verwierf. Maar overhaast je reis in geen geval. 120. K. En vind je het er wat pover. hen zul je niet ontmoeten op je weg wanneer je denken hoog blijft. pleisteren in Phoenicische handelssteden om daar aantrekkelijke dingen aan te schaffen van parelmoer. ‘t Is beter dat die vele jaren duurt. Amsterdam: Bert Bakker. wanneer je geest hun niet gestalte voor je geeft. koraal. Daar aan te komen is je doel. Kavafis Vertaald uit het Grieks: Hans Warren en Mario Molegraaf (1986) Gedichten. Dat er veel zomermorgens zullen komen waarop je. ook opwindende geurstoffen van alle soorten. 141 Acknowledgements . vol ervaringen.P. vol avonturen. de woedende Poseidon zul je niet treffen wanneer je ze niet in eigen geest meedraagt.

Hans Hovens. During these 142 . Met veel genoegen denk ik terug aan de reizen naar de VS om te presenteren bij de International Society for the Study of Trauma and Dissociation (ISSTD). We have never met and I am looking forward to meeting you in person on the 10th of June 2011. en Rolf Kleber.en dissociatieliteratuur. hoewel we er net iets anders over denken. Suzette Boon. Ik vind het heel bijzonder om mee te maken hoezeer jij daar gewaardeerd wordt en hier “gewoon” je gang gaat.Gedurende de jaren dat ik aan dit project heb gewerkt. Ik ben je zeer gaan waarderen: Je bent altijd goed gezelschap en steeds beschikbaar voor goede raad op velerlei gebieden. Jullie zijn vertegenwoordigers uit verschillende velden van het vakgebied en ik waardeer het dat jullie tijd en moeite hebben genomen dit proefschrift te beoordelen. en Peter van der Heijden. heb ik veel van dit onderzoeksproject geleerd en heeft het me ook veel gebracht. Door jou heb ik in Utrecht mijn faalangst voor statistiek overwonnen: Gewoon nuchter blijven denken en verder niet moeilijker maken dan nodig is. Ik ken weinig mensen die zo’n diversiteit aan thema’s. Ik heb me daardoor overal welkom gevoeld. Wij hebben elkaar aan de Universiteit Utrecht leren kennen. Veel dank aan Onno. Onderzoek doen trok me altijd al aan. Onno van der Hart. Aan de Universiteit Utrecht was ik weer in de gelegenheid om een onderzoek op te zetten. Ford. maar mijn pad liep anders. ik ken je sinds mijn studietijd als docent statistiek in het psychologie onderwijs van de Universiteit van Leiden. Kathy Steele. sinds onze kennismaking tijdens het selectiegesprek voor de opleiding tot klinisch psycholoog ken jij me in diverse rollen en levensfasen. De laatste jaren heb je vele deuren voor me geopend en me kennis laten maken met jouw dierbare collega’s in binnen.en buitenland (waar onder Ellert Nijenhuis. Je integere. wat uitgemond is in ons eerste artikel over positieve en negatieve dissociatieve symptomen bij soldaten aan het front in de Eerste Wereld Oorlog. Als eerste dank aan mijn promotoren: Maarten van Son. en Bessel van der Kolk). A special thanks to my dear co-author Julian D. Ook een handige strategie buiten de statistiek! Dank ook aan de beoordelingscommissie voor het lezen en goedkeuren van dit proefschrift: Anneloes van Baar. Je hebt me veel geleerd en me gestimuleerd me te verdiepen in de (Franse) trauma. de selectie van de samenwerkingspartners. Nel Draijer. de onderzoeksopzet en de veelheid aan producten die het heeft opgeleverd. De afstemming tussen onze ideeën over dissociatie en affect disregulatie is in harmonie verlopen. Julian Ford. Graag gebruik ik dit deel van het proefschrift om een aantal mensen te bedanken die hebben bijgedragen aan het welslagen van dit project. Peter. en ook humorvolle manier van begeleiden waardeer ik zeer en ik hecht veel waarde aan je mening en oordeel. Maarten. Jan van de Bout. Ik heb veel van je geleerd en leer nog steeds van je. Je hebt in diverse stadia essentiële bijdragen geleverd in het ontstaan van het project. taken en verantwoordelijkheden in zich verenigen. Bessel van der Kolk. rollen. betrokken. Maar vooral je steun in mijn diverse ondernemingen is me zeer dierbaar. Vanaf het begin af aan was je enthousiast voor het project. With relentless energy and enthusiasm you have joined the project and have been sharpening our ideas on dysfunctional affect regulation. Onno introduced us and I thank him ever since for that.

years of cooperation I have learned a great deal from you. I do hope that in the future we can continue to cooperate. I whish you and your wife Judy a wonderful time in the Netherlands and Europe. Also special thanks to Bessel van der Kolk, who’s work has been a major source of inspiration for this study on dysfunctional affect regulation. Despite your busy schedule, on several occasions you have been available to brainstorm with me on the nature of affect dysregulation. Also, I appreciate your creative mind on the exploration and assessment of phenomena associated with trauma and dysfunctional affect regulation, and the pursuit of new avenues in the treatment of adverse and sometimes long term consequences of chronic childhood trauma. Met veel genoegen heb ik een aantal jaren aan de Universiteit Utrecht gewerkt als universitair docent voor de capaciteitsgroep Klinische psychologie. Deze omgeving was zeer inspirerend voor het verder uitkristalliseren van het onderzoeksproject. Dank hiervoor aan alle collega’s, ook aan diegenen werkzaam bij de andere capaciteitsgroepen. Het mogen winnen van de onderwijsprijs 2001 vind ik nog altijd een hele eer. Ik hecht er veel waarde aan dat ik het eindproduct van het onderzoeksproject in de vorm van een dissertatie, juist hier mag verdedigen. Altrecht Psychosomatiek heeft vanaf het ontwikkelen van het onderzoeksproject een belangrijke rol gespeeld. Martina Bühring (beleidspsychiater Altrecht Psychosomatiek) wil ik bedanken voor het adopteren van dit onderzoeksproject. Veel waarde hecht ik aan het vertrouwen en de vrijheid die je me geschonken hebt de inhoud van de producten van het project vorm te geven. De steun aan het symposium dat voorafgaat aan de promotieplechtigheid is daar een mooi voorbeeld van. Dank ook aan Wim Snellen (hoofd psychodiagnostiek Altrecht) en Frederike Lether (manager Altrecht Psychosomatiek) en alle collega’s en stagiaires die in de loop der jaren bij Altrecht Psychosomatiek hebben gewerkt en hebben bijgedragen in de begeleiding van de dataverzameling, verwerking en het schrijven van de psychodiagnostische verslagen. En uiteraard ook dank aan alle participerende patiënten van Altrecht Psychosomatiek. In het bijzonder aandacht aan Annelies Plekker: van een collega, een hartsvriendin , nu ook mijn paranimf geworden! Je klinische kennis en ervaringen in de psychosomatiek en universitaire onderzoekswereld hebben mij zeer gestimuleerd om door te blijven gaan. Ik heb prettig met je samengewerkt op Altrecht Psychosomatiek/ Eikenboom en later heb je me overgehaald om als behandelaar in Delta Psychiatrisch Centrum te komen werken bij De Waard. Zonder jouw onvoorwaardelijke en belangeloze steun op deze twee onderzoeksites was het wellicht nooit zover gekomen. Delta Psychiatrisch Ziekenhuis, Deltabouman, Delta Psychiatrisch Centrum. In verschillende samenstellingen en fasen werkte ik samen met verschillende collega’s; hen dank ik van harte. Allereerst Wim Paling die me weliswaar meteen aannam als hoofd psychodiagnostiek en het onderzoeksproject vanaf het begin onvoorwaardelijk gesteund heeft, maar

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nooit is gestopt kritische noten te plaatsen bij al mijn ondernemingen. Het oude bestuur, Jaap Bakker en Eddie Schuyer, die bleven beklemtonen dat wetenschappelijk onderzoek in een perifeer psychiatrisch ziekenhuis weliswaar gewenst was, maar vooral ten goede moest komen aan de directe patiëntenzorg. Voorts dank ik de clusterleiding van het toenmalige Cluster Gespecialiseerde Behandelingen: Rob Ruimschotel (cluster psychiater) en Peter van Hese (clustermanager) voor het adopteren van het onderzoeksproject en mijzelf als behandelaar. Naast de reeds genoemde Annelies Plekker, wil ik ook graag het voltallige team van De Waard bedanken voor de mooie tijd die we samen gehad hebben bij het implementeren van de Observatie- en Oriëntatiefase zoals beschreven in hoofdstuk 6 van dit proefschrift. Laten we het weer doen! Dank ook aan de medewerkers van de afdeling psychodiagnostiek, post-master opleidelingen en alle onderzoeksstagiaires voor hun steun en medewerking aan dit onderzoeksproject en aan gelieerde onderzoeksprojecten. Zonder hun inzet had ik het niet kunnen volbrengen. Veel dank aan alle participerende patiënten van Delta Psychiatrisch Centrum. Daarnaast dank aan Willem de Vries (internist) voor zijn inzet in de diagnostiek van somatische en psychosomatische stoornissen en de behandeling van patiënten die onder onze gezamenlijke hoede stonden, altijd met hulp van Carolien Hool (diabetes verpleegkundige). Hans Hovens (A-opleider) en Anton Loonen (arts, klinisch farmacoloog) dank ik voor hun adviezen bij het door de METC loodsen van het onderzoeksproject, steun in het proces van volharden en herschrijven van ideeën en artikelen, en overleven in een snel veranderende GGZ. Dank ook aan het “nieuwe” bestuur, Paul van Heugten en Wouter Teer, die soms met verwondering mijn ondernemingen hebben aanschouwd, maar het onderzoeksproject hebben gesteund en nog steeds steunen. Een veranderende instelling heeft als voordeel dat je met verschillende collega’s en in steeds wisselende teams mag participeren. Ook maak ik nog wel eens “uitstapjes” naar andere gezondheidszorg instellingen. Dank aan alle collega’s voor meeleven in het wel en wee van het project en de gezelligheid. Sinds bijna twee jaar maak ik deel uit van het team Nieuwe Kennis: Ik zou in geen ander team willen werken. In het bijzonder dank ik Brenda Bootsma voor haar loyaliteit en gezelligheid. Maar zeker ook voor de introductie in de wereld van de verpleegkundigen en hun expertise, waaronder ook Excellente Zorg en de opleiding tot verpleegkundig specialist. In het onderzoeksproject heb ik ook op deelprojecten met anderen samengewerkt die allen hun bijdrage hebben geleverd aan het aanscherpen en uitwerken van de ideeën. Graag wil ik voor wat betreft de statistiek noemen Laurence Frank (Universiteit Utrecht). Laurence, ik bewonder je geduld en precisie in het nakijken van de dataset en de syntax. Ik hoop dat onze path-analyses-artikelen snel een plaatsje in een mooi tijdschrift mogen krijgen. Verder wil ik graag André Aleman (UMC Groningen) en Mascha van ’t Wout (Brown University, Rhode Island) bedanken voor de prettige onderzoekssamenwerking op het gebied van de neuropsychologie en de schizofrenie. Ik hoop dat ons artikel snel gepubliceerd wordt en er zijn nog meer data verzameld dus: Wordt vervolgd!

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Mijn belangstelling voor mensen en hun emoties moet ergens “vroeg” ontstaan zijn. In mijn privé-leven heb ik goede herinneringen aan discussies in mijn kindertijd over dit thema in mijn moeders zogenoemde onderwijs-circuit. Van de middelbare school kan ik eigenlijk alleen maar discussies over mensen, emoties en gedrag herinneren. In het bijzonder wil ik Pieter de Nijs noemen. Samen zaten we op het Jansenius. Hoewel we ook hele periodes geen contact hebben gehad, waren tussentijdse toevallige ontmoetingen in onze studententijd in de trein of op de boot naar Zeeuws Vlaanderen altijd plezierig en inspirerend. Niet zelden volgde bij het uitstappen een opmerking van een medepassagier dat ze nog nooit zo’n onbegrijpelijke discussie had gehoord over klassieke muziek, het brein, de psychologie, dialecten, etymologie, docenten van Jansenius, oud-klasgenoten, en het wel en wee van het leven in Zeeuws Vlaanderen. Sinds ik in Poortugaal woon, hebben wij meer structureel contact. Ik vind het fijn dat je mijn paranimf wil zijn. Al bij aanvang van mijn studie psychologie in Leiden wist ik dat ik iets met emoties en gezondheidszorg ging doen. Het kiezen van de studierichting was makkelijk. Een paar docenten uit die tijd dank ik bij dezen voor hun inspiratie. Bij klinische en gezondheidpsychologie Willem Heuves en Liesbeth Eurelings-Bontekoe. Liesbeth, je werd al snel een rolmodel, maar je bent absoluut niet bij te houden! Dierbare herinneringen heb ik aan het team van pepy: persoonlijkheidspsychologie en psychodiagnostiek. Eerst als student en later als assistent kreeg ik de gelegenheid om alle facetten van academisch werken en denken te exploreren. Helaas werd pepy opgeheven en vervloog mijn uitzicht op een aio-plek. Uiteindelijk is er dan toch een proefschrift gekomen. Peter Paul Moormann, Franciene Albach, en Bob Bermond (UvA) inspireerden en introduceerden me in de alexithymia-literatuur en -onderzoek. Het mooie is dat we nog steeds contact hebben. Speciaal wil ik Peter Paul en Franciene danken voor hun vriendschap. Onderwijs en supervisies in de opleiding tot klinisch psycholoog hebben geholpen ideeën over alexithymia, trauma’s in de kindertijd, impulsiviteit en onverklaarde lichamelijke klachten verder te laten rijpen. Ik bedank alle collega’s voor het reflecteren over de diagnostiek en behandeling van mensen met een trauma in de voorgeschiedenis, ik heb er veel van geleerd. Kosse, dat jij je over Jasmijn ontfermt als ik weer naar een congres in binnen of buitenland ga, wordt zeer gewaardeerd. Ik hoop dat we onze dochter Jasmijn tot een mooi mens mogen laten opgroeien. HOME IS WHERE WE START FROM (Winnicott, 1990). Emoties hebben altijd een rol gespeeld thuis, ook vanwege het feit dat ik een ouder zusje heb gehad dat maar een paar dagen heeft geleefd. Ik heb een lieve vader gehad die helaas te vroeg overleden is. Hij bracht me onder andere verantwoordelijkheidsgevoel, mildheid, doorzettingsvermogen en een zekere onverzettelijkheid bij. Mijn moeder heeft een groot hart. Menig verdrietige of gestrande scholier van allerlei pluimage bracht ik mee naar huis om zich bij ons te laven of te voeden. Mijn moeder heeft nooit iemand geweigerd te ontvangen. Geheel tegen haar zin

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Dankzij haar verhuizing met ons naar Poortugaal. Haar loyaliteit aan mij en Jasmijn is groot. Ik prijs me gelukkig dat ik uit een goed en veilig gezin kom. angst en verdriet verdwijnen als sneeuw voor de zon. Bovendien heb ik dit proefschrift kunnen afmaken. niets is zo helend en vertederend als jouw enthousiaste begroeting bij het weerzien en daarna jouw armen om mij heen. kan Jasmijn toch vaak thuis zijn terwijl ik werk en mijn nevenactiviteiten doe. En je weet: Een kusje van jou. En een keertje ruzie is niet erg want wat er ook gebeurt: Wij horen bij elkaar! 146 .in ben ik psychologie gaan studeren. Lieve Jasmijn. Promoveren vindt ze geweldig. doet boosheid.

Curriculum Vitae .

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paper presentations and poster presentations. As from 2002 onward she is head supervisor of the post-master education for behavioral sciences (P-opleider) at Delta Psychiatric Hospital (Poortugaal) and has trained several general health psychologists. chairing symposia and participating in discussion panels. Jansenius. She has been teaching on treatment of depression. Bouman Mental Health (addiction). and a master in “personality theories and assessment” and carried out several clinical and research internships in hospital and university settings. she went studying Psychology at Leiden University. As from September 2010 to current she is part-time head of department of research and knowledge development of the Dutch Chronic Trauma Center (Landelijk Centrum Vroegkinderlijke chronische Traumatisering. Between 1988 en 1994 she was trained in a master in “clinical and health psychology”. the Netherlands. somatoform disorders. Benecke) and as a guest-lecturer for Tilburg University and Leiden University. After she graduated from S. she specialized in cognitive-behavior therapy and became a full member of the Dutch Association for CBT. both in in-patient and out-patients facilities. During this period she worked as a clinician for several Mental Health Institutions across the country (P. PAO. assessment (neuropsychological and personality assessment). LCVT). From 1998 to current she is assistant-director of the post-master education Leiden/Rotterdam-area for general health psychologists (hoofddocent Gz-opleiding).G. At various national and international conferences from 1995 onward she has been presenting her clinical work and research findings in clinically oriented workshops. RIAGG Westhage. After her graduation she became a lecturer at the College for Higher Education in Social and Agogic Work (Hogeschool voor Social-Agogisch Onderwijs) in The Hague.CURRICULUM VITAE Annemiek van Dijke was born on the 21st of July 1969 in Hulst. she continued her education with specialized professional education in clinical psychology and psychotherapy (KP en PT opleiding Stichting PDO GGZ Leiden/ Utrecht). From 2004 onward she has been a member of several bodies for the professional education of psychologists: 149 Curriculum Vitae . and clinical neuropsychologists for Delta Psychiatric Center. and assessment and treatment of complex trauma-related disorders for various post-master education institutions (RINO groep. & RIAGG Gooi-en Vechtstreek). and seconded for Forensic Psychiatric Center De Kijvelanden. She was an assistant-professor at Utrecht University at the department of Clinical and Health Psychology (1998 to 2002) and coordinator of psychopathology. In the same year she became an research-assistant for several research projects as well as education-assistant for the department of “Personality theories and Assessment” at Leiden University. Cure & Care. Also. and both with children and adults. and Breburg Mental Health. In 1999 she became officially registered as a clinical psychologist and psychotherapist. clinical psychologists. From 1995 onward.C. In 2009 she became also officially registered as a clinical neuropsychologist and a member of the curriculum committee.and psychological assessment-courses. She was awarded with the assistant-professor-of-the-year-prize in 2001/2002. Bloemendaal.

and the Regulatory Body for Advanced and Specialized Professional Education (CSG: College Specialismen Gezondheidszorg psycholoog). Supervisory Body for the Professional Education of Health Care Psychologists (KGzP: Kamer Gezondheidszorg psycholoog).Supervisory Body for Advanced and Specialized Professional Education (FGzP-RSG: Registratie Commissie specialismen van de Gezondheidszorg psycholoog). 150 .

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behavioral. reflective.and affect regulation is considered a core component in BPD and SoD. -some authors have considered BPD and SoD to be disorders of affect regulation. somatic. relational. and psycho-physiological functioning.it is of empirical and clinical relevance to differentiate forms of dysfunctional affect regulation. . cognitive. Van Dijke described dysfunctional self and affect regulation as operating in vicious cycles that approach the long-term sequelae of trauma-by-primary-caretaker from a developmental perspective. Symptoms include disturbances in selfregulation across several domains of functioning including affective. executive. Excitatory-. and combined Inhibitory & Excitatory (IE)-regulation.As dysfunctional self. Dysfunctional regulation may present in patients in three qualitatively different forms: Inhibitory-.

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